Department of Surgical Scienceshttp://hdl.handle.net/1956/956
Sun, 02 Aug 2015 22:56:05 GMT2015-08-02T22:56:05ZLeg cramps in pregnancy caused by chronic compartment syndrome and relieved by fasciotomy after childbirthhttp://hdl.handle.net/1956/9525
Leg cramps in pregnancy caused by chronic compartment syndrome and relieved by fasciotomy after childbirth
Orlin, Jan; Øen, Jarle; Andersen, John Roger; Tjugum, Jostein; Westbye, Hans Jacob; Roska, Jomar; Aasved, Helene; Hjelmeland, Kjersti
Journal article
<strong>Key Clinical Message</strong> <p>A case of intolerable leg pain in pregnancy, caused by Chronic Compartment
Syndrome (CCS), is presented. Increasing amounts of opioids were given
throughout the pregnancy. Anesthetical dilemmas and surgery are discussed. In
conclusion, early surgery rather than opioids is recommended.</p>
Sun, 01 Jun 2014 00:00:00 GMThttp://hdl.handle.net/1956/95252014-06-01T00:00:00ZInter-hospital transfer: the crux of the trauma system, a curse for trauma registrieshttp://hdl.handle.net/1956/9443
Inter-hospital transfer: the crux of the trauma system, a curse for trauma registries
Lossius, Hans Morten; Kristiansen, Thomas; Ringdal, Kjetil Gorseth; Rehn, Marius
Journal article
The inter-hospital transfer of patients is crucial to a well functioning trauma system, and the transfer process may serve as a quality indicator for regional trauma care. However, the assessment of the transfer process requires high-quality data from various sources. Prospective studies and studies based on single-centre trauma registries may fail to capture an appropriate width and depth of data. Thus the creation of inclusive regional and national trauma registries that receive information from all of the services within a trauma system is a prerequisite for high quality inter-hospital transfer studies in the future.
Tue, 16 Mar 2010 00:00:00 GMThttp://hdl.handle.net/1956/94432010-03-16T00:00:00ZRisk factors for knee replacement due to primary osteoarthritis, a population based, prospective cohort study of 315,495 individualshttp://hdl.handle.net/1956/9424
Risk factors for knee replacement due to primary osteoarthritis, a population based, prospective cohort study of 315,495 individuals
Apold, Hilde; Meyer, Haakon E.; Nordsletten, Lars; Furnes, Ove; Baste, Valborg; Flugsrud, Gunnar B.
Journal article
<p>Background: Osteoarthritis (OA) of the knee is a common and disabling condition. We wanted to investigate the modifiable risk factors Body Mass Index (BMI) and physical activity, using knee replacement (KR) as a marker for severely symptomatic disease, focusing on the interaction between these risk factors.</p>
<p>Methods: 315,495 participants (mean age 43.0 years) from national health screenings were followed prospectively with respect to KR identified by linkage to the Norwegian Arthroplasty Register. Data were analysed by Cox proportional hazard regression.</p>
<p>Results: During 12 years of follow up 1,323 individuals received KR for primary OA. There was a dose&ndash;response relationship between BMI and heavy labour, and later KR. Comparing the highest versus the lowest quarter of BMI, the relative risk was 6.2 (95% CI: 4.2-9.0) in men and 11.1 (95% CI: 7.8-15.6) in women. Men reporting intensive physical activity at work had a relative risk of 2.4 (95% CI: 1.8-3.2) versus men reporting sedentary activity at work, the corresponding figure in women being 2.3 (95% CI: 1.7-3.2). The effect of BMI and physical activity at work was additive. The heaviest men with the most strenuous work had a RR of 11.7 (95% CI: 5.9-23.1) compared to the ones with the lowest BMI and most sedentary work. For women the corresponding RR was 15.8 (95% CI: 8.2-30.3). There was no association between physical activity during leisure and KR.</p>
<p>Conclusion: We found that a high BMI and intensive physical activity at work both contribute strongly to the risk of having a KR. As the two risk factors seem to act independently, people with strenuous physical work with a high BMI are at particularly high risk for severely disabling OA of the knee, and should be targeted with effective preventive measures.</p>
Mon, 23 Jun 2014 00:00:00 GMThttp://hdl.handle.net/1956/94242014-06-23T00:00:00Z"Getting your message through": an editorial guide for meeting publication standardshttp://hdl.handle.net/1956/9295
"Getting your message through": an editorial guide for meeting publication standards
Ringdal, Kjetil Gorseth; Lossius, Hans Morten; Søreide, Kjetil
Journal article
Wed, 23 Dec 2009 00:00:00 GMThttp://hdl.handle.net/1956/92952009-12-23T00:00:00ZA consensus-based template for uniform reporting of data from pre-hospital advanced airway managementhttp://hdl.handle.net/1956/9288
A consensus-based template for uniform reporting of data from pre-hospital advanced airway management
Sollid, Stephen J. M.; Lockey, David J.; Lossius, Hans Morten; Pre-hospital advanced airway management expert group
Journal article
<p>Background: Advanced airway management is a critical intervention that can harm the patient if performed poorly. The available literature on this subject is rich, but it is difficult to interpret due to a huge variability and poor definitions. Several initiatives from large organisations concerned with airway management have recently propagated the need for guidelines and standards in pre-hospital airway management. Following the path of other initiatives to establish templates for uniform data reporting, like the many Utstein-style templates, we initiated and carried out a structured consensus process with international experts to establish a set of core data points to be documented and reported in cases of advanced pre-hospital airway management.</p>
<p>Methods: A four-step modified nominal group technique process was employed.</p>
<p>Results: The inclusion criterion for the template was defined as any patient for whom the insertion of an advanced airway device or ventilation was attempted. The data points were divided into three groups based on their relationship to the intervention, including system-, patient-, and postintervention variables, and the expert group agreed on a total of 23 core data points. Additionally, the group defined 19 optional variables for which a consensus could not be achieved or the data were considered as valuable but not essential.</p>
<p>Conclusion: We successfully developed an Utstein-style template for documenting and reporting pre-hospital airway management. The core dataset for this template should be included in future studies on pre-hospital airway management to produce comparable data across systems and patient populations and will be implemented in systems that are influenced by the expert panel.</p>
Fri, 20 Nov 2009 00:00:00 GMThttp://hdl.handle.net/1956/92882009-11-20T00:00:00ZTrauma systems and early management of severe injuries in scandinavia: review and current statushttp://hdl.handle.net/1956/9241
Trauma systems and early management of severe injuries in scandinavia: review and current status
Kristiansen, Thomas; Søreide, Kjetil; Ringdal, Kjetil Gorseth; Rehn, Marius; Krüger, Andreas J.; Reite, Andreas; Meling, Terje; Næss, Pål Aksel; Lossius, Hans Morten
Journal article
Fri, 28 Aug 2009 00:00:00 GMThttp://hdl.handle.net/1956/92412009-08-28T00:00:00ZA year of contemplation: looking back and moving forwardhttp://hdl.handle.net/1956/9228
A year of contemplation: looking back and moving forward
Søreide, Kjetil; Lossius, Hans Morten
Journal article
Mon, 13 Jul 2009 00:00:00 GMThttp://hdl.handle.net/1956/92282009-07-13T00:00:00ZSubmission policy, peer-review and editorial board members: interesting conflicts and conflicts of interesthttp://hdl.handle.net/1956/9131
Submission policy, peer-review and editorial board members: interesting conflicts and conflicts of interest
Søreide, Kjetil; Ringdal, Kjetil Gorseth; Lossius, Hans Morten; Editors of the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Journal article
The Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine welcomes an ever-increasing number of submissions while maintaining an acceptance level well below half of all submitted manuscripts, meaning that the number and quality of submitted papers are increasing. As has been stated in the past, the editors endorse a number of guidelines in order to improve presentation and style as well as adherence to current standards in publishing. Notably, all papers submitted to the SJTREM and potentially deemed suitable for publication will undergo peer-review from at least 2 (and often more) referees before making a final decision to accept or reject. Due to an increasing number of case reports, the decision to immediately reject those deemed unsuitable for the SJTREM has become more rigorous. The SJTREM wishes to maintain a main focus on original articles, review articles and solicited commentaries to selected studies
Tue, 26 Oct 2010 00:00:00 GMThttp://hdl.handle.net/1956/91312010-10-26T00:00:00ZOpen access publishing: a girder in the success of the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.http://hdl.handle.net/1956/9130
Open access publishing: a girder in the success of the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine.
Lossius, Hans Morten; Søreide, Kjetil
Journal article
The Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (SJTREM) has entered its third year as an independent, open access international scientific on-line journal. SJTREM converted into open access (OA) online publishing in July 2008. The decision was based on the importance of making research accessible for all, regardless of financial status or capabilities. This conversion resulted in a substantial rise in submissions, and not least citations. Scandinavian research founders have for the last two years been steadily moving from a supportive attitude for the OA principles, to making policy decisions that have a direct guidance to authors to publish OA. The Scandinavian move is part of the wider global picture where mandates and funding mechanisms, constituting the equivalent of library budgets at many universities, are springing into life. With the support of European Commission, OA are evolving all over Europe. As a result of such initiatives, the list of universities with central funds for OA publications is growing rapidly. The OA conversion of SJTREM was timely, and the number papers cited in other journals are increasing. All published papers reach a significant number of readers, far above what was achievable for the earlier paper version of SJTREM.
Wed, 19 Jan 2011 00:00:00 GMThttp://hdl.handle.net/1956/91302011-01-19T00:00:00ZEsophageal perforation: Diagnostic work-up and clinical decision-making in the first 24 hourshttp://hdl.handle.net/1956/8773
Esophageal perforation: Diagnostic work-up and clinical decision-making in the first 24 hours
Søreide, Jon Arne; Viste, Asgaut
Journal article
Abstract
Esophageal perforation is a rare and potentially life-threatening condition. Early clinical suspicion and imaging is important for case management to achieve a good outcome. However, recent studies continue to report high morbidity and mortality greater than 20% from esophageal perforation. At least half of the perforations are iatrogenic, mostly related to endoscopic instrumentation used in the upper gastrointestinal tract, while about a third are spontaneous perforations. Surgical treatment remains an important option for many patients, but a non-operative approach, with or without use of an endoscopic stent or placement of internal or external drains, should be considered when the clinical situation allows for a less invasive approach. The rarity of this emergency makes it difficult for a physician to obtain extensive individual clinical experience; it is also challenging to obtain firm scientific evidence that informs patient management and clinical decision-making. Improved attention to non-specific symptoms and signs and early diagnosis based on imaging may translate into better outcomes for this group of patients, many of whom are elderly with significant comorbidity.
Sun, 30 Oct 2011 00:00:00 GMThttp://hdl.handle.net/1956/87732011-10-30T00:00:00ZA consensus-based template for documenting and reporting in physician-staffed pre-hospital serviceshttp://hdl.handle.net/1956/8729
A consensus-based template for documenting and reporting in physician-staffed pre-hospital services
Krüger, Andreas J.; Lockey, David; Kurola, Jouni; Di Bartolomeo, Stefano; Castrén, Maaret; Mikkelsen, Søren; Lossius, Hans Morten
Journal article
<p>Background: Physician-staffed pre-hospital units are employed in many Western emergency medical services (EMS) systems. Although these services usually integrate well within their EMS, little is known about the quality of care delivered, the precision of dispatch, and whether the services deliver a higher quality of care to pre-hospital patients. There is no common data set collected to document the activity of physician pre-hospital activity which makes shared research efforts difficult. The aim of this study was to develop a core data set for routine documentation and reporting in physician-staffed pre-hospital services in Europe.</p>
<p>Methods: Using predefined criteria, we recruited sixteen European experts in the field of pre-hospital care. These experts were guided through a four-step modified nominal group technique. The process was carried out using both e-mail-based communication and a plenary meeting in Stavanger, Norway.</p>
<p>Results: The core data set was divided into 5 sections: &ldquo;fixed system variables&rdquo;, &ldquo;event operational descriptors&rdquo;, &ldquo; patient descriptors&rdquo;, &ldquo;process mapping&rdquo;, and &ldquo;outcome measures and quality indicators&rdquo;. After the initial round, a total of 361 variables were proposed by the experts. Subsequent rounds reduced the number of core variables to 45. These constituted the final core data set. Emphasis was placed on the standardisation of reporting time variables, chief complaints and diagnostic and therapeutic procedures.</p>
<p>Conclusions: Using a modified nominal group technique, we have established a core data set for documenting and reporting in physician-staffed pre-hospital services. We believe that this template could facilitate future studies within the field and facilitate standardised reporting and future shared research efforts in advanced prehospital care.</p>
Wed, 23 Nov 2011 00:00:00 GMThttp://hdl.handle.net/1956/87292011-11-23T00:00:00ZPatient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providershttp://hdl.handle.net/1956/8657
Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers
Lossius, Hans Morten; Røislien, Jo; Lockey, David J.
Journal article
<p>Introduction: Pre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety.</p>
<p>Methods: We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene.</p>
<p>Results: From 1,070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixtyfour per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (P = 0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI) and, comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955, respectively (P = 0.047).</p>
<p>Conclusions: This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered.</p>
Sat, 11 Feb 2012 00:00:00 GMThttp://hdl.handle.net/1956/86572012-02-11T00:00:00ZAre two readers more reliable than one? A study of upper neck ligament scoring on magnetic resonance imageshttp://hdl.handle.net/1956/8521
Are two readers more reliable than one? A study of upper neck ligament scoring on magnetic resonance images
Espeland, Ansgar; Vetti, Nils; Kråkenes, Jostein
Journal article
<p>Background: Magnetic resonance imaging (MRI) studies typically employ either a single expert or multiple readers in collaboration to evaluate (read) the image results. However, no study has examined whether evaluations from multiple readers provide more reliable results than a single reader. We examined whether consistency in image interpretation by a single expert might be equal to the consistency of combined readings, defined as independent interpretations by two readers, where cases of disagreement were reconciled by consensus.</p>
<p>Methods: One expert neuroradiologist and one trained radiology resident independently evaluated 102 MRIs of the upper neck. The signal intensities of the alar and transverse ligaments were scored 0, 1, 2, or 3. Disagreements were resolved by consensus. They repeated the grading process after 3&ndash;8 months (second evaluation). We used kappa statistics and intraclass correlation coefficients (ICCs) to assess agreement between the initial and second evaluations for each radiologist and for combined determinations. Disagreements on score prevalence were evaluated with McNemar&rsquo;s test.</p>
<p>Results: Higher consistency between the initial and second evaluations was obtained with the combined readings than with individual readings for signal intensity scores of ligaments on both the right and left sides of the spine. The weighted kappa ranges were 0.65-0.71 vs. 0.48-0.62 for combined vs. individual scoring, respectively. The combined scores also showed better agreement between evaluations than individual scores for the presence of grade 2&ndash;3 signal intensities on any side in a given subject (unweighted kappa 0.69-0.74 vs. 0.52-0.63, respectively). Disagreement between the initial and second evaluations on the prevalence of grades 2&ndash;3 was less marked for combined scores than for individual scores (P &ge; 0.039 vs. P &le; 0.004, respectively). ICCs indicated a more reliable sum score per patient for combined scores (0.74) and both readers&rsquo; average scores (0.78) than for individual scores (0.55-0.69).</p>
<p>Conclusions: This study was the first to provide empirical support for the principle that an additional reader can improve the reproducibility of MRI interpretations compared to one expert alone. Furthermore, even a moderately experienced second reader improved the reliability compared to a single expert reader. The implications of this for clinical work require further study.</p>
Thu, 17 Jan 2013 00:00:00 GMThttp://hdl.handle.net/1956/85212013-01-17T00:00:00ZTrauma systems in Norway: implementation of national recommendations three years down the linehttp://hdl.handle.net/1956/8496
Trauma systems in Norway: implementation of national recommendations three years down the line
Kristiansen, Thomas; Lossius, Hans Morten; Ringdal, Kjetil Gorseth
Conference object
Thu, 22 Mar 2012 00:00:00 GMThttp://hdl.handle.net/1956/84962012-03-22T00:00:00ZClassification of comorbidity in trauma: agreement and reliability of the pre-injury ASA-PS Scalehttp://hdl.handle.net/1956/8494
Classification of comorbidity in trauma: agreement and reliability of the pre-injury ASA-PS Scale
Ringdal, Kjetil Gorseth; Skaga, Nils Oddvar; Steen, Petter Andreas; Hestnes, Morten; Laake, Petter; Jones, J. Mary; Lossius, Hans Morten
Conference object
Thu, 22 Mar 2012 00:00:00 GMThttp://hdl.handle.net/1956/84942012-03-22T00:00:00ZA randomized study on migration of the Spectron EF and the Charnley flanged 40 cemented femoral components using radiostereometric analysis at 2 yearshttp://hdl.handle.net/1956/7931
A randomized study on migration of the Spectron EF and the Charnley flanged 40 cemented femoral components using radiostereometric analysis at 2 years
Kadar, Thomas; Hallan, Geir; Aamodt, Arild; Indrekvam, Kari; Badawy, Mona; Havelin, Leif Ivar; Stokke, Terje; Haugan, Kristin; Espehaug, Birgitte; Furnes, Ove
Journal article
<p>Background and purpose: We performed a randomized study
to determine the migration patterns of the Spectron EF femoral
stem and to compare them with those of the Charnley stem,
which is regarded by many as the gold standard for comparison
of implants due to its extensive documentation.</p><p>Patients and methods: 150 patients with a mean age of 70 years
were randomized, single-blinded, to receive either a cemented
Charnley flanged 40 monoblock, stainless steel, vaquasheen surface
femoral stem with a 22.2-mm head (n = 30) or a cemented
Spectron EF modular, matte, straight, collared, cobalt-chrome
femoral stem with a 28-mm femoral head and a roughened proximal
third of the stem (n = 120). The patients were followed with
repeated radiostereometric analysis for 2 years to assess migration.</p><p>Results: At 2 years, stem retroversion was 2.3° and 0.7°
(p &lt; 0.001) and posterior translation was 0.44 mm and 0.17 mm
(p = 0.002) for the Charnley group (n = 26) and the Spectron EF
group (n = 74), respectively. Subsidence was 0.26 mm for the
Charnley and 0.20 mm for the Spectron EF (p = 0.5).</p><p>Interpretation: The Spectron EF femoral stem was more stable
than the Charnley flanged 40 stem in our study when evaluated
at 2 years. In a report from the Norwegian arthroplasty register,
the Spectron EF stem had a higher revision rate due to aseptic
loosening beyond 5 years than the Charnley. Initial stability
is not invariably related to good long-term results. Our results
emphasize the importance of prospective long-term follow-up of
prosthetic implants in clinical trials and national registries and a
stepwise introduction of implants.</p>
Sat, 01 Oct 2011 00:00:00 GMThttp://hdl.handle.net/1956/79312011-10-01T00:00:00ZHip dysplasia in young adultshttp://hdl.handle.net/1956/7693
Hip dysplasia in young adults
Engesæter, Ingvild Øvstebø
Doctoral thesis
<p>According to data held by the Medical Birth Registry of Norway, approximately 1% of all newborns in Norway are diagnosed annually with hip instability at birth. Abduction treatment (Frejka pillow) for 6-12 weeks is the standard treatment in Norway, with which the majority will develop normal hips. Additionally to those detected by the neonatal screening program, some are late-diagnosed cases (diagnosis &gt;1 month of age). For this group, the treatment is usually more demanding and prolonged. The older the child is at start of treatment, the poorer is the prognosis. A dysplastic hip causes altered mechanical conditions, predisposing for increased wear of the cartilage and development of osteoarthritis of the hip in young adult age. The final treatment option for this condition could be a total hip replacement.</p><p>In Paper I, we linked two national registries, the Norwegian Arthroplasty Register and the Medical Birth Registry of Norway, using the unique national identification number. The Birth Registry contains information on all newborns in Norway from 1967 and the Arthroplasty Register includes all total hip replacements inserted in Norway from 1987. The study found a 2.6 times increased risk for a total hip replacement in young adulthood for patients reported with hip instability in the newborn period. The absolute risk was however low at only 57 in 105 for patients with hip instability compared to 20 in 105 for those with stable hips. Only 8% of those who underwent a total hip replacement due to hip dysplasia were reported to have had instable hips at birth.</p><p>In Paper II, we validated the dysplasia diagnosis reported to the Norwegian Arthroplasty Register for subjects born after 1967. Medical records were reviewed and we also investigated age at dysplasia diagnosis, previous treatment and quality of life. We found the dysplasia diagnosis reported to the Arthroplasty Register to be correct in 88% of the hips. Median age at time of diagnosis was as high as 7.8 years: 4.4 years for females and 22 years for males. 75% of the patients had undergone different hip-preserving treatments before their prosthesis, and the dysplasia patients scored poorer in quality of life (EQ-5D) compared to the age-matched general population in Sweden and the UK.</p><p>In Paper III, we aimed to validate a digital measurement programme for hip dysplasia at skeletal maturity. Ninety-five radiographs were measured by three independent observers in both a newly developed digital measurement programme and manually in AgfaWeb1000. Eleven radiological measurements, all relevant for hip dysplasia at skeletal maturity, were evaluated. We found acceptable inter- and intra-observer reproducibility for most measurements, but with poorer accuracy for measurements with small absolute values. The reproducibility was relatively similar for the two methods used, but the digital measurements were performed much faster.</p><p>In Paper IV, we used data from the 1989 Hip Project and reported on the prevalence of hip dysplasia in 2081 19-year old Norwegians. The prevalence of hip dysplasia in the cohort varied from 1.7% to 20% depending on the radiological measurement used. A Wiberg’s angle &lt;20° was seen in 3.3% of the cohort: 4.3% in women and 2.4% in men. We found no association between subjects with radiological signs indicating hip dysplasia and body mass index (BMI), Beighton hypermobility score, EQ-5D score or WOMAC score.</p><p>The overall conclusions of this thesis are as follows: About 25% of all total hip replacements in young adults (&lt; 40 years) are performed due to an underlying hip dysplasia. The dysplasia diagnosis is in general detected late, indicating that clinical testing for hip instability in newborns is an insufficient screening method to detect hips that require a total hip replacement in young adulthood. Several radiographic measurements for hip dysplasia are proposed in the literature. The reproducibility for these measurements varies, but with acceptable results for the more common measurements such as Wiberg’s centre-edge and Sharp’s acetabular angle. The prevalence of hip dysplasia is highly dependent on the radiographic measurements used, but a high prevalence for some of the measurements is found in skeletally mature Norwegians as compared to other studies on Caucasians in the literature.</p>
Fri, 08 Nov 2013 00:00:00 GMThttp://hdl.handle.net/1956/76932013-11-08T00:00:00ZTotal hip replacement in young adults with hip dysplasia. Age at diagnosis, previous treatment, quality of life, and validation of diagnoses reported to the Norwegian Arthroplasty Register between 1987 and 2007http://hdl.handle.net/1956/7692
Total hip replacement in young adults with hip dysplasia. Age at diagnosis, previous treatment, quality of life, and validation of diagnoses reported to the Norwegian Arthroplasty Register between 1987 and 2007
Engesæter, Ingvild Øvstebø; Lehmann, Trude; Laborie, Lene Bjerke; Lie, Stein Atle; Rosendahl, Karen; Engesæter, Lars B.
Peer reviewed; Journal article
<p>Background and purpose: Dysplasia of the hip increases the
risk of secondary degenerative change and subsequent total hip
replacement. Here we report on age at diagnosis of dysplasia, previous
treatment, and quality of life for patients born after 1967
and registered with a total hip replacement due to dysplasia in
the Norwegian Arthroplasty Register. We also used the medical
records to validate the diagnosis reported by the orthopedic surgeon
to the register.</p><p>Methods: Subjects born after January 1, 1967 and registered
with a primary total hip replacement in the Norwegian
Arthroplasty Register during the period 1987–2007 (n = 713)
were included in the study. Data on hip symptoms and quality of
life (EQ-5D) were collected through questionnaires. Elaborating
information was retrieved from the medical records.</p><p>Results: 540 of 713 patients (76%) (corresponding to 634 hips)
returned the questionnaires and consented for additional information
to be retrieved from their medical records. Hip dysplasia
accounted for 163 of 634 hip replacements (26%), 134 of which
were in females (82%). Median age at time of diagnosis was 7.8
(0–39) years: 4.4 years for females and 22 years for males. After
reviewing accessible medical records, the diagnosis of hip dysplasia
was confirmed in 132 of 150 hips (88%).</p><p>Interpretation: One quarter of hip replacements performed in
patients aged 40 or younger were due to an underlying hip dysplasia,
which, in most cases, was diagnosed during late childhood.
The dysplasia diagnosis reported to the register was correct for
88% of the hips.</p>
Fri, 01 Apr 2011 00:00:00 GMThttp://hdl.handle.net/1956/76922011-04-01T00:00:00ZIntramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractureshttp://hdl.handle.net/1956/7600
Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures
Matre, Kjell; Havelin, Leif Ivar; Gjertsen, Jan-Erik; Espehaug, Birgitte; Fevang, Jonas Meling
Peer reviewed; Journal article
<p><strong>Background</strong> Sliding hip screws (SHSs) and intramedullary
(IM) nails are well-documented implants for simple
two-part intertrochanteric fractures; however, there is no
consensus regarding which type of implant is better.</p>
<p><strong>Questions/purposes</strong> We asked whether patients with
simple two-part intertrochanteric fractures treated with IM
nailing had (1) a lower reoperation rate and (2) less pain
and better quality of life than patients treated with SHSs.</p>
Mon, 01 Apr 2013 00:00:00 GMThttp://hdl.handle.net/1956/76002013-04-01T00:00:00ZTRIGEN INTERTAN Intramedullary Nail Versus Sliding Hip Screwhttp://hdl.handle.net/1956/7599
TRIGEN INTERTAN Intramedullary Nail Versus Sliding Hip Screw
Matre, Kjell; Vinje, Tarjei; Havelin, Leif Ivar; Gjertsen, Jan-Erik; Furnes, Ove; Espehaug, Birgitte; Kjellevold, Stein-Harald; Fevang, Jonas Meling
Peer reviewed; Journal article
<p><strong>Background:</strong> Both intramedullary nails and sliding hip screws are used with good results in the treatment of intertrochanteric
and subtrochanteric fractures. The aim of our study was to assess whether use of the TRIGEN INTERTAN nail, as
compared with a sliding hip screw, resulted in less postoperative pain, improved functional mobility, and reduced surgical
complication rates for patients with an intertrochanteric or subtrochanteric fracture.</p><p><strong>Methods:</strong> In a prospective, randomized multicenter study, 684 elderly patients were treated with the INTERTAN nail or
with a sliding hip screw with or without a trochanteric stabilizing plate. The patients were assessed during their hospital
stay and at three and twelve months postoperatively. A visual analogue scale (VAS) pain score was recorded at all time
points, and functional mobility was assessed with use of the timed Up & Go test. The Harris hip score (HHS) was used to
assess hip function more specifically. Quality of life was measured with the EuroQol-5D (EQ-5D). Radiographic findings as
well as intraoperative and postoperative complications were recorded and analyzed.</p><p><strong>Results:</strong> Patients treated with an INTERTAN nail had slightly less pain at the time of early postoperative mobilization (VAS score,
48 versus 52; p = 0.042), although this did not influence the length of the hospital stay and there was no difference at three or
twelve months. Regardless of the fracture and implant type, functional mobility, hip function, patient satisfaction, and quality-of-life
assessments were comparable between the groups at three and twelve months. The numbers of patients with surgical complications
were similar for the two groups (twenty-nine in the sliding-hip-screw group and thirty-two in the INTERTAN group, p = 0.67).</p><p><strong>Conclusions:</strong> INTERTAN nails and sliding hip screws are similar in terms of pain, function, and reoperation rates twelve
months after treatment of intertrochanteric and subtrochanteric fractures.</p>
Wed, 06 Feb 2013 00:00:00 GMThttp://hdl.handle.net/1956/75992013-02-06T00:00:00ZTreatment of trochanteric and subtrochanteric hip fractures: Sliding hip screw or intramedullary nail?http://hdl.handle.net/1956/7583
Treatment of trochanteric and subtrochanteric hip fractures: Sliding hip screw or intramedullary nail?
Matre, Kjell
Doctoral thesis
<p><strong>Background:</strong> Trochanteric and subtrochanteric fractures are usually treated with a sliding hip screw (SHS) or an intramedullary (IM) nail, and the question whether a SHS or an IM nail should be the preferred implant for all or subgroups of fractures has not come to a final
conclusion. In recent years, there has been a trend towards more use of IM nails, but
this trend has not been driven by better results in well designed clinical trials.
Regardless of type of implant, complications have to be encountered and to which
extent modern implants have improved results remains unclear.</p>
<p><strong>Aims:</strong> It was our first aim to assess whether treatment with the new TRIGEN INTERTAN intramedullary nail resulted in less postoperative pain, better function, and improved
quality of life for patients with trochanteric and subtrochanteric fractures compared to
treatment with the SHS (Papers I and IV). Surgical complications and reoperation
rates were also assessed.</p>
<p>Secondly, we wanted to compare postoperative pain, function, quality of life, and
reoperation rates for patients operated with IM nails and SHS for different subgroups
of trochanteric and subtrochanteric fractures at a national level (Papers II and III).</p>
<p><strong>Patients and methods:</strong> 684 elderly patients with trochanteric and subtrochanteric fractures were included and treated with a SHS or the Intertan nail in a multicenter randomized controlled trial (RCT) (Paper I). The patients were assessed during hospital stay and at 3 and 12 months postoperatively. The 159 patients with reverse oblique trochanteric (AO/OTA type A3) and subtrochanteric fractures were separately analyzed and discussed in depth (Paper IV).</p>
<p>Using data from the Norwegian Hip Fracture Register in papers II and III, we analyzed
7643 operations for simple two-part trochanteric fractures (AO/OTA type A1) (Paper II) and 2716 operations for reverse oblique and subtrochanteric fractures (Paper III) after treatment with either a SHS or an IM nail.</p>
<p><strong>Results:</strong> As presented in Papers I and IV patients operated with the Intertan nail had slightly less pain at early postoperative mobilization compared to those operated with a SHS, but we found no difference at 12 months. Regardless of fracture type, mobility, hip
function, quality of life, and surgical complication rates were comparable for the two
groups at 12 months.</p>
<p>In simple two-part trochanteric fractures (Paper II) the SHSs had a lower
complication rate compared to IM nails one year postoperatively (2.4% and 4.2% for
SHS and IM nail, respectively, p = 0.001). Only minor, and clinically insignificant
differences between the groups were found for pain, patient satisfaction, and quality of
life.</p>
<p>In Paper III, conversely, we found that the patients operated with an IM nail had a
significantly lower failure rate compared to the SHS one year postoperatively (3.8% vs.
6.4%, respectively, p = 0.011). Small differences regarding pain, patient satisfaction,
quality of life, and mobility were also in favor of IM nailing.</p>
<p><strong>Conclusions:</strong> Pain, function, quality of life, and reoperation rates were similar for the Intertan nail
and the SHS in trochanteric and subtrochanteric fractures 12 months postoperatively.</p>
<p>Data from our hip fracture register, however, favored the SHS in simple two- part
trochanteric fractures, whereas IM nails had the lower complication rate and better
clinical results in reverse oblique and subtrochanteric fractures. Accordingly, a
differentiated treatment algorithm based on fracture type could be considered.</p>
Fri, 19 Apr 2013 00:00:00 GMThttp://hdl.handle.net/1956/75832013-04-19T00:00:00ZPatient-Reported Outcome Measures after Endoscopic Retrograde Cholangiopancreatography: A Prospective, Multicenter Studyhttp://hdl.handle.net/1956/7582
Patient-Reported Outcome Measures after Endoscopic Retrograde Cholangiopancreatography: A Prospective, Multicenter Study
Glomsaker, Tom Birger; Hoff, Geir; Kvaløy, Jan Terje; Søreide, Kjetil; Aabakken, Lars; Søreide, Jon Arne; The Norwegian Gastronet ERCP group
Journal article
<p><strong>Objective:</strong> While patient-reported outcome measures (PROMs) in ERCP are scarce, these reports are important for making improvements in quality of care. This study sought to document patient satisfaction and specifically pain related to endoscopic retrograde cholangiopancreatography (ERCP) procedures and to identify predictors for these experiences.</p><p><strong>Methods</strong> From 2007 through 2009, prospective data from consecutive ERCP procedures at 11 hospitals during normal daily practice were recorded. Information regarding undesirable events that occurred during a 30-day follow-up period was also reported. The patient-reported pain, discomfort and general satisfaction with the ERCP were recorded.</p><p><strong>Results:</strong> Data from 2808 ERCP procedures were included in this study. Patient questionnaires were returned for 52.6% of the procedures. Moderate or severe pain was experienced in 15.5% and 14.0% of the procedures during the ERCP and in 10.8% and 7.7% of the procedures after the ERCP, respectively. In addition, female gender, endoscopic sphincterotomy (EST), and longer procedure times served as independent predictors of increased pain during the ERCP. The performing hospitals and sedation regimens were independent predictors of the procedural pain experience. In 90.9% of the procedures, the patients were satisfied with the information overall, and in 98.3% of the procedures, the patients were satisfied with the treatment provided. Independent predictors of dissatisfaction with the treatment included the occurrence of specific complications after ERCP and pain during or after the procedure.</p><p><strong>Conclusions:</strong> Female gender, the performance of EST and longer procedure times were independent predictors for increased procedure-related pain. The individual hospital and sedation regimen predicts the patient's pain experience.</p>
Tue, 01 Jan 2013 00:00:00 GMThttp://hdl.handle.net/1956/75822013-01-01T00:00:00ZEndoscopic retrograde cholangiopancreatography (ERCP) in Norway: Patterns of activity and undesired eventshttp://hdl.handle.net/1956/7581
Endoscopic retrograde cholangiopancreatography (ERCP) in Norway: Patterns of activity and undesired events
Glomsaker, Tom Birger
Doctoral thesis
<p><strong>Background:</strong> Endoscopic retrograde cholangiopancreatography (ERCP) is the gold
standard for the treatment of common bile duct stones (CBDS) and palliative
decompression of malignant strictures. However, concerns remain regarding
procedure-related complications and patient discomfort and pain. National data on
ERCP are lacking, and international data on risk factors for complications and patient
experiences are sparse and ambiguous.</p><p><strong>Objectives:</strong> In this project, we wanted to (1) collect national figures on ERCP
activity and local routines in Norway over a period of 11 years, between 1998 and
2008; (2) describe and evaluate routine clinical ERCP practices in Norway over three
years (2007 –2009); (3) evaluate the incidence of complications and (30-day)
mortality, and identify possible risk factors for undesired outcomes after ERCP; and
(4) evaluate patient pain and satisfaction after ERCP, and investigate potential
predictors of pain and dissatisfaction.</p><strong>Methods:</strong> Based on surveys conducted in all Norwegian hospitals, data were
collected on ERCP activity at four time points. As a part of a voluntary, national,
Quality Assurance (QA) program in Gastronet, ERCP procedures were registered
prospectively at 14 different hospitals in Norway, and these data were collected for
the present study. Based on consecutive, registration and reporting, including a 30-
day follow up from 11 hospitals, a descriptive evaluation of the ERCP activity per se,
and specifically of complications was performed. Statistical analyses were performed to identify independent risk factors for complications, procedure-related pain, and
patient dissatisfaction.</p><p><strong>Results:</strong> In the first paper, a total of 42,260 procedures were reported over 11 years
(average 3842 procedures per year, range 3492-4632). During that time, the number
of hospitals that offered ERCP decreased from 41 to 35, and the annual number of
procedures decreased by 13% (from 4632 to 4036). However, the number of ERCPtrained
endoscopists in Norway remained stable (≈100). The proportion of surgical
procedures decreased from 40% to 32% (p<0.001) during the first 6 years. Regional
variations in ERCP volumes decreased during the study period. In paper 2, 3781
procedures performed at 14 hospitals were registered. Reliable data from 3683
procedures (53% females and 47% males) were available for evaluation. In 2488
(67%) of the ERCP procedures, the patients were at least 60 years of age. High
comorbidity (ASA score 3-4) was reported in 33% of patients. The main indication
for ERCP was a need for evaluation and therapy of common bile duct (CBD)-related
symptoms and signs. A pre-cut sphincterotomy (EST) was performed in 5% of
procedures, and a guide-wire was employed to facilitate duct access in 61% of
procedures. The median total procedure time was 28 min (IQR 19-40). CBD stones
(CBDS) or strictures of the CBD were diagnosed in over 75% of procedures. Specific
diseases related to the pancreatic ducts were reported in only 6% of procedures.
Biliary EST was performed in 46% of procedures. In addition to EST, CBDS treatment and CBD stent insertions or manipulations were the most common
procedures. In papers 3 and 4, 2808 ERCP procedures were reported; of these, 2573
(91.6%) were therapeutic. CBD cannulation was achieved in 2557 (91.1%)
procedures. Complications occurred in 327 (11.6%) procedures, including cholangitis
(n=100; 3.6%), pancreatitis (n=88; 3.1%), bleeding (n=66; 2.4%), perforation (n=25;
0.9%), and cardiovascular-respiratory events (n=32; 1.1%). Older age, high ASA
score, annual ERCP volumes >150 procedures/center, and pre-cut ESTs were
independent predictive factors for severe complications. Overall, the 30-day mortality
was 2.2% (63 patients), with a possible procedure-related mortality rate of 1.4% (39
patients). The patient questionnaire was returned for 52.6% of procedures. Moderate
or severe pain, respectively, was experienced in 15.5% and 14.0% of procedures
during the ERCP and in 10.8% and 7.7% of procedures after the ERCP. In addition,
female gender, EST, and longer procedure times were independent predictors of
increased pain during the ERCP. The performing hospital was an independent
predictor (p<0.001) of procedural pain experience. In 90.9% of procedures, the
patients were satisfied with the information provided; overall, 98.3% of patients were
satisfied with the treatment. However, the occurrences of specific complications after
ERCP, and pain during or after the procedure were independent predictors for
dissatisfaction with the treatment.</p><p><strong>Conclusions:</strong> Regional variation in the number of ERCPs performed appeared to
have diminished. Patient selection, indications, and procedures employed in Norway
were consistent with international guidelines and recommendations. Disease patterns
partly differed from patterns reported both in middle Europe and in the US. ERCP-related morbidity and mortality and differences between units in reported outcome
remain a concern. A mandatory, electronic, national registry with more resources is
needed to continue a QA program for ERCP.</p>
Thu, 21 Mar 2013 00:00:00 GMThttp://hdl.handle.net/1956/75812013-03-21T00:00:00ZInfection after primary hip arthroplasty. Epidemiology, time trends and risk factors in data from national health registers. The Norwegian Arthroplasty Registerhttp://hdl.handle.net/1956/7388
Infection after primary hip arthroplasty. Epidemiology, time trends and risk factors in data from national health registers. The Norwegian Arthroplasty Register
Dale, Håvard
Doctoral thesis
<p>Every year, more than 10,000 Norwegians undergo hip replacement (7,360 THAs and 3,214 HAs in 2011). This may be due to osteoarthritis (OA), inflammatory joint disease, fractures, fracture sequelae, aseptic femoral head necrosis or sequelae after childhood hip disease. The native hip joint is replaced by a total hip arthroplasty (THA) or a hemiarthroplasty (HA). The implants constitute large foreign bodies that could be predilection spots for adherence of microorganisms, and postoperative infections are a feared complication. Such infections are difficult to treat and impose increased morbidity and mortality on the patients.</p><p>To meet the challenge of prosthetic joint infection, several risk factors have been identified and prophylactic measures have been introduced. The Norwegian Arthroplasty Register (NAR) has had several publications on antibiotic prophylaxis, systemically and in bone cement, for THA, and probably contributed to that Norwegian orthopaedic surgeons changed their routines. The starting point of the present PhD project was to assess whether these changes in antibiotic prophylaxis had changed the risk of revision due to infection.</p><p>We found that, in spite of the anticipated improved antibiotic prophylaxis, the risk of revision due to infection after primary THA had increased threefold from 1987-1992 to 2003-2007 (Paper I). In the Nordic Arthroplasty Register Association’s (NARA) dataset from Denmark, Finland, Norway and Sweden, a similar increase in risk of revision due to infection after primary THA was found between 1995-1999 and 2005-2009 (Paper III). The reason for this increase could not be explained by any known changes in the risk factors assessed in the two studies (Papers I and III). The possibility of a true increase in prosthetic joint infection and other possible explanations were discussed.</p><p>In Norway there are no systematic registrations of true prosthetic joint infection. Revisions due to infection should be reported to the NAR and the Norwegian Hip Fracture Register (NHFR), and surgical site infections should be reported to the Norwegian Surveillance System for Healthcare-Associated Infections (NOIS). In Paper II we assessed risk factors and risk patterns for these two endpoints for both THA and HA. The first-year incidence of surgical site infection after primary arthroplasty was found to be nearly five times higher than the first-year incidence of revision due to infection. There also seems to be differences in the risk patterns between surgical site infection and revision due to infection and between HA and THA. </p><p>The risk factors associated with increased risk of revision due to infection after primary THA were male sex, advanced age (70-90 years when adjusted for comorbidity), comorbidity (ASA class &gt; 1), long duration of surgery (&gt; 100 minutes), uncemented or hybrid fixation, bone cement without antibiotics, laminar air flow in the operation room, NNIS risk index higher than one, and THA performed due to inflammatory disease, hip fracture or femoral head necrosis.</p><p>Risk factors of surgical site infection after THA was advanced age (&gt; 80 years), comorbidity (ASA class &gt; 2), and short duration of surgery (&lt; 60 minutes).</p><p>For primary HAs the only risk factor associated with increased risk of revision due to infection was young age (&lt; 60 years), whereas no statistically significant risk factors of surgical site infection were identified.</p><p>The overall conclusion of this thesis is that the risk of revision due to infection after primary THA has been increasing. Definite causes of this increased risk could not be established in the three papers. Considering risk factors and possible confounders we still believe that there might have been a true increase in the incidence of prosthetic joint infection.</p>
Fri, 08 Feb 2013 00:00:00 GMThttp://hdl.handle.net/1956/73882013-02-08T00:00:00ZIncreasing risk of prosthetic joint infection after total hip arthroplasty. 2,778 revisions due to infection after 432,168 primary THAs in the Nordic Arthroplasty Register Association (NARA)http://hdl.handle.net/1956/7373
Increasing risk of prosthetic joint infection after total hip arthroplasty. 2,778 revisions due to infection after 432,168 primary THAs in the Nordic Arthroplasty Register Association (NARA)
Dale, Håvard; Fenstad, Anne Marie; Hallan, Geir; Havelin, Leif Ivar; Furnes, Ove; Overgaard, Søren; Pedersen, Alma B.; Kärrholm, Johan; Garellick, Göran; Pulkkinen, Pekka; Eskelinen, Antti; Mäkelä, Keijo; Engesæter, Lars B.
Journal article; Peer reviewed
<p>Background and purpose: The risk of revision due to infection
after primary total hip arthroplasty (THA) has been reported to
be increasing in Norway. We investigated whether this increase
is a common feature in the Nordic countries (Denmark, Finland,
Norway, and Sweden).</p><p>Materials and methods The study was based on the Nordic
Arthroplasty Register Association (NARA) dataset. 432,168 primary
THAs from 1995 to 2009 were included (Denmark: 83,853,
Finland 78,106, Norway 88,455, and Sweden 181,754). Adjusted
survival analyses were performed using Cox regression models
with revision due to infection as the endpoint. The effect of risk
factors such as the year of surgery, age, sex, diagnosis, type of
prosthesis, and fixation were assessed.</p><p>Results: 2,778 (0.6%) of the primary THAs were revised due
to infection. Compared to the period 1995–1999, the relative
risk (with 95% CI) of revision due to infection was 1.1 (1.0–1.2)
in 2000–2004 and 1.6 (1.4–1.7) in 2005–2009. Adjusted cumulative
5–year revision rates due to infection were 0.46% (0.42–
0.50) in 1995–1999, 0.54% (0.50–0.58) in 2000–2004, and 0.71%
(0.66–0.76) in 2005–2009. The entire increase in risk of revision
due to infection was within 1 year of primary surgery, and most
notably in the first 3 months. The risk of revision due to infection
increased in all 4 countries. Risk factors for revision due to infection
were male sex, hybrid fixation, cement without antibiotics,
and THA performed due to inflammatory disease, hip fracture,
or femoral head necrosis. None of these risk factors increased in
incidence during the study period.</p><p>Interpretation: We found increased relative risk of revision
and increased cumulative 5–year revision rates due to infection
after primary THA during the period 1995–2009. No change in
risk factors in the NARA dataset could explain this increase. We
believe that there has been an actual increase in the incidence of
prosthetic joint infections after THA.</p>
Mon, 01 Oct 2012 00:00:00 GMThttp://hdl.handle.net/1956/73732012-10-01T00:00:00ZInfection after primary hip arthroplasty. A comparison of 3 Norwegian health registershttp://hdl.handle.net/1956/7372
Infection after primary hip arthroplasty. A comparison of 3 Norwegian health registers
Dale, Håvard; Skråmm, Inge; Løwer, Hege Line; Eriksen, Hanne M.; Espehaug, Birgitte; Furnes, Ove; Skjeldestad, Finn Egil; Havelin, Leif Ivar; Engesæter, Lars B.
Journal article; Peer reviewed
<p>Background and purpose: The aim of the present study was to assess incidence of and risk factors for infection after hip arthroplasty in data from 3 national health registries. We investigated differences in risk patterns between surgical site infection (SSI) and revision due to infection after primary total hip arthroplasty (THA) and hemiarthroplasty (HA).</p><p>Materials and methods: This observational study was based on prospective data from 2005–2009 on primary THAs and HAs from the Norwegian Arthroplasty Register (NAR), the Norwegian Hip Fracture Register (NHFR), and the Norwegian Surveillance System for Healthcare–Associated Infections (NOIS). The Norwegian Patient Register (NPR) was used for evaluation of case reporting. Cox regression analyses were performed with revision due to infection as endpoint for data from the NAR and the NHFR, and with SSI as the endpoint for data from the NOIS.</p><p>Results: The 1–year incidence of SSI in the NOIS was 3.0% after THA (167/5,540) and 7.3% after HA (103/1,416). The 1–year incidence of revision due to infection was 0.7% for THAs in the NAR (182/24,512) and 1.5% for HAs in the NHFR (128/8,262). Risk factors for SSI after THA were advanced age, ASA class higher than 2, and short duration of surgery. For THA, the risk factors for revision due to infection were male sex, advanced age, ASA class higher than 1, emergency surgery, uncemented fixation, and a National Nosocomial Infection Surveillance (NNIS) risk index of 2 or more. For HAs inserted after fracture, age less than 60 and short duration of surgery were risk factors of revision due to infection.</p><p>Interpretation: The incidences of SSI and revision due to infection after primary hip replacements in Norway are similar to those in other countries. There may be differences in risk pattern between SSI and revision due to infection after arthroplasty. The risk patterns for revision due to infection appear to be different for HA and THA.</p>
Thu, 01 Dec 2011 00:00:00 GMThttp://hdl.handle.net/1956/73722011-12-01T00:00:00ZIncreasing risk of revision due to deep infection after hip arthroplasty. A study on 97,344 primary total hip replacements in the Norwegian Arthroplasty Register from 1987 to 2007http://hdl.handle.net/1956/7371
Increasing risk of revision due to deep infection after hip arthroplasty. A study on 97,344 primary total hip replacements in the Norwegian Arthroplasty Register from 1987 to 2007
Dale, Håvard; Hallan, Geir; Espehaug, Birgitte; Havelin, Leif Ivar; Engesæter, Lars B.
Journal article; Peer reviewed
<p>Background and purpose: Over the decades, improvements in
surgery and perioperative routines have reduced the incidence
of deep infections after total hip arthroplasty (THA). There is,
however, some evidence to suggest that the incidence of infection
is increasing again. We assessed the risk of revision due to
deep infection for primary THAs reported to the Norwegian
Arthroplasty Register (NAR) over the period 1987-2007.</p> <p>Method: We included all primary cemented and uncemented
THAs reported to the NAR from September 15, 1987 to January
1, 2008 and performed adjusted Cox regression analyses with the
first revision due to deep infection as endpoint. Changes in revision
rate as a function of the year of operation were investigated.</p> <p>Results: Of the 97,344 primary THAs that met the inclusion
criteria, 614 THAs had been revised due to deep infection (S-year
survivaI 99.46%). Risk of revision due to deep infection increased
throughout the period studied. Compared to the THAs implanted
in 1987-1992, the risk of revision due to infection was 1.3 times
higher (95%CI: 1.0-1.7) for those implanted in 1993-1997, 1.5
times (95% Cl: 1.2-2.0) for those implanted in 1998-2002, and
3.0 times (95% Cl: 2.2-4.0) for those implanted in 2003-2007.
The most pronounced increase in risk of being revised due to
deep infection was for the subgroup of uncemented THAs from
2003-2007, which had an increase of 5 times (95% Cl: 2.6-11)
compared to uncemented THAs from 1987-1992.</p> <p>Interpretation: The incidence of deep infection after THA
increased during the period 1987-2007. Concomitant changes in
confounding factors, however, complicate the interpretation of the
results.</p>
Tue, 01 Dec 2009 00:00:00 GMThttp://hdl.handle.net/1956/73712009-12-01T00:00:00ZNo effect of 6-month intake of glucosamine sulfate on Modic changes or high intensity zones in the lumbar spine: sub-group analysis of a randomized controlled trialhttp://hdl.handle.net/1956/7212
No effect of 6-month intake of glucosamine sulfate on Modic changes or high intensity zones in the lumbar spine: sub-group analysis of a randomized controlled trial
Wilkens, Philip; Storheim, Kjersti; Scheel, Inger; Berg, Linda; Espeland, Ansgar
Journal article; Peer reviewed
<p>Background: The underlying pathology and natural course of Modic changes (MC) in the vertebral body marrow
and high intensity zones (HIZs) in the annulus fibrosus is not completely clarified. These findings on magnetic
resonance imaging (MRI) have initiated different treatments with little or unclear effect. In a randomized trial
(n = 250), glucosamine sulfate (GS) had no effect on low back pain related disability. GS could still have an effect on
MC and HIZ. In this sub-study, 45 patients from the trial who had MC and/or HIZ at pre-treatment underwent
follow-up MRI. The aim was to examine the course of MC and HIZ and to compare this course between groups
treated with 6-month intake of oral GS versus placebo.</p> <p>Results: Of 141 pre-treatment MC in 42 (of 45) patients, 29 (20.6%) MC in 18 patients had altered type and 14 MC
in 9 patients had altered size (decreased for 1 MC) 6-18 months later: odds ratio (OR) for type vs. size alterations 4.0;
95% confidence interval (CI) 1.2-17.7. No MC resolved. HIZ vanished from 3 of 23 discs in 3 of 21 patients with
pre-treatment HIZ. Ten new MC (all type I or I/II) occurred in 8 patients and 2 new HIZs in 2 patients. The GS group
(n = 19) and placebo group (n = 26) did not differ in proportions of MC with decreased (OR 1.6; 95% CI 0.4-6.1) or
increased type I dominance at follow-up (OR placebo:GS 2.4; 95% CI 0.6-9.7), or with increased size (OR 1.0; 95% CI
0.2-4.7). HIZ vanished from 1 of 8 discs in 1 of 8 patients in the GS group vs. 2 of 15 discs in 2 of 13 patients in the
placebo group (OR 0.8; 95% CI 0.02-12.2).</p><p>Conclusions: In this sub-group analysis of a placebo-controlled trial, the effect of GS on MC and HIZs was no
different from the effect of the placebo intervention. MC and HIZs remained mostly unchanged during the
6-18 months study period. Some short term changes did occur and MC more often altered type than size.</p>
Fri, 17 Aug 2012 00:00:00 GMThttp://hdl.handle.net/1956/72122012-08-17T00:00:00ZIncreased incidence of postoperative infections during prophylaxis with cephalothin compared to doxycycline in intestinal surgeryhttp://hdl.handle.net/1956/7211
Increased incidence of postoperative infections during prophylaxis with cephalothin compared to doxycycline in intestinal surgery
Baatrup, Gunnar; Nilsen, Roy Miodini; Svensen, Rune; Akselsen, Per E.
Journal article; Peer reviewed
<p>Background: The antibiotics used for prophylaxis during surgery may influence the rate of surgical
site infections. Tetracyclines are attractive having a long half-life and few side effects when used in
a single dose regimen. We studied the rate of surgical site infections during changing regimens of
antibiotic prophylaxis in medium and major size surgery.</p><p>Methods: Prospective registration of surgical site infection following intestinal resections and
hysterectomies was performed. Possible confounding procedure and patient related factors were
registered. The study included 1541 procedures and 1489 controls. The registration included time
periods when the regimen was changed from doxycycline to cephalothin and back again.</p> <p>Results: The SSI in the colorectal department increased from 19% to 30% (p = 0.002) when
doxycycline was substituted with cephalothin and decreased to 17% when we changed back to
doxycycline (p = 0.005). In the gynaecology department the surgical site infection rate did not
increase significantly. Subgroup analysis showed major changes in infections in rectal resections
from 20% to 35% (p = 0.02) and back to 12% (p = 0.003).</p><p>Conclusion: Doxycycline combined with metronidazole, is an attractive candidate for antibiotic
prophylaxis in medium and major size intestinal surgery.</p>
Mon, 07 Dec 2009 00:00:00 GMThttp://hdl.handle.net/1956/72112009-12-07T00:00:00ZAn economic model to evaluate cost-effectiveness of computer assisted knee replacement surgery in Norwayhttp://hdl.handle.net/1956/7121
An economic model to evaluate cost-effectiveness of computer assisted knee replacement surgery in Norway
Gøthesen, Øystein Johannes; Slover, James; Havelin, Leif Ivar; Askildsen, Jan Erik; Malchau, Henrik; Furnes, Ove
Journal article; Peer reviewed
<p>Background: The use of Computer Assisted Surgery (CAS) for knee replacements is intended to improve the
alignment of knee prostheses in order to reduce the number of revision operations. Is the cost effectiveness of
computer assisted surgery influenced by patient volume and age?</p> <p>Methods: By employing a Markov model, we analysed the cost effectiveness of computer assisted surgery versus
conventional arthroplasty with respect to implant survival and operation volume in two theoretical Norwegian age
cohorts. We obtained mortality and hospital cost data over a 20-year period from Norwegian registers. We
presumed that the cost of an intervention would need to be below NOK 500,000 per QALY (Quality Adjusted Life
Year) gained, to be considered cost effective.</p> <p>Results: The added cost of computer assisted surgery, provided this has no impact on implant survival, is NOK
1037 and NOK 1414 respectively for 60 and 75-year-olds per quality-adjusted life year at a volume of 25 prostheses
per year, and NOK 128 and NOK 175 respectively at a volume of 250 prostheses per year. Sensitivity analyses
showed that the 10-year implant survival in cohort 1 needs to rise from 89.8% to 90.6% at 25 prostheses per year,
and from 89.8 to 89.9% at 250 prostheses per year for computer assisted surgery to be considered cost effective. In
cohort 2, the required improvement is a rise from 95.1% to 95.4% at 25 prostheses per year, and from 95.10% to
95.14% at 250 prostheses per year.</p> <p>Conclusions: The cost of using computer navigation for total knee replacements may be acceptable for 60-year-old
as well as 75-year-old patients if the technique increases the implant survival rate just marginally, and the
department has a high operation volume. A low volume department might not achieve cost-effectiveness unless
computer navigation has a more significant impact on implant survival, thus may defer the investments until such
data are available.</p>
Sat, 06 Jul 2013 00:00:00 GMThttp://hdl.handle.net/1956/71212013-07-06T00:00:00ZLong-term survival from adenocarcinoma of the esophagus after transthoracic and transhiatal esophagectomyhttp://hdl.handle.net/1956/6642
Long-term survival from adenocarcinoma of the esophagus after transthoracic and transhiatal esophagectomy
Øvrebø, Kjell; Lie, Stein Atle; Laerum, Ole D.; Svanes, Knut; Viste, Asgaut
Peer reviewed; Journal article
<p>Background: The effects of transthoracic or transhiatal esophagectomy on the long-term survival of patients who had adenocarcinoma of the esophagus were compared, as were factors applicable in preoperative stratification of patient treatment.</p> <p>Methods: A cohort of 147 consecutive patients with adenocarcinoma of the esophagus was evaluated for esophagectomy between 1984 and 2000. The patients were followed prospectively and observed survival rates of patients with a transthoracic or transhiatal approach to esophagectomy were compared by standardized mortality ratio (SMR) and relative mortality ratio (RMR) using the expected survival of a matched Norwegian population.</p> <p>Results: A R0 resection was performed by transthoracic (n = 33) or a transhiatal (n = 55) esophagectomy in 88 (60%) patients with a median age of 61 (range: 35–77) and 70 (42–88) years, respectively (P <0.001). Tumor stages and other possible risk factors were similar in the two groups. Transthoracic or transhiatal esophagectomy resulted in a median survival time of 20.5 (95% confidence interval (CI): 10.4–57.6) and 16.4 (10.6–28.7) months, respectively. The respective survival rates were 31.2% and 27.8% by 5 years, and 21.3% and 16.6% by 10 years with an overall RMR of 1.14 (P = 0.63). Median survival time in the absence or presence of lymph node metastases was 74.0 (95% CI: 17.5–166.4) and 10.7 (7.9–14.9) months. The corresponding survival rates by 10 years with non-involved or involved nodes were 48.9% and 3.8% respectively (RMR 2.22, P = 0.007). Patients with a pT1-tumor were few and the survival rate was not very different from that of the general population (SMR = 1.7, 95% CI: 0.7–4.1). The median survival time of patients with a pT2-tumor was 30.4 (95% CI: 9.0–142) months and with a pT3-tumor 14 (9.2–16.4) months. The survival rates by 10 years among patients with a pT1 tumor were 57.0% (95% CI: 14.9–78.9), pT2 33.3% (11.8–52.2), and pT3 7.1% (1.9–15.5). The relative mortality for T3 stages compared to T1 stages was statistically significant (RMR = 3.22, P = 0.024).</p> <p>Conclusion: Transthoracic and transhiatal esophagectomy are both effective approaches for treatment of adenocarcinoma of the esophagus and survival of more than 10 years can be expected without adjuvant chemotherapy. However, increasing depth of tumor invasion and lymph node metastases reduce life expectancy.</p>
Sat, 30 Jun 2012 00:00:00 GMThttp://hdl.handle.net/1956/66422012-06-30T00:00:00ZImplementation of recommended trauma system criteria in south-eastern Norway: a cross-sectional hospital surveyhttp://hdl.handle.net/1956/6633
Implementation of recommended trauma system criteria in south-eastern Norway: a cross-sectional hospital survey
Kristiansen, Thomas; Ringdal, Kjetil Gorseth; Skotheimsvik, Tarjei; Salthammer, Halvor K.; Gaarder, Christine; Næss, Pål A.; Lossius, Hans Morten
Peer reviewed; Journal article
<p>Background: Formalized trauma systems have shown beneficial effects on patient survival and have harvested great recognition among health care professionals. In spite of this, the implementation of trauma systems is challenging and often met with resistance. Recommendations for a national trauma system in Norway were published in 2007. We wanted to assess the level of implementation of these recommendations.</p> <p>Methods: A survey of all acute care hospitals that receive severely injured patients in the south-eastern health region of Norway was conducted. A structured questionnaire based on the 2007 national recommendations was used in a telephone interview of hospital trauma personnel between January 17 and 21, 2011. Seventeen trauma system criteria were identified from the recommendations.</p> <p>Results: Nineteen hospitals were included in the study and these received more than 2000 trauma patients annually via their trauma teams. Out of the 17 criteria that had been identified, the hospitals fulfilled a median of 12 criteria. Neither the size of the hospitals nor the distance between the hospitals and the regional trauma centre affected the level of trauma resources available. The hospitals scored lowest on the criteria for transfer of patients to higher level of care and on the training requirements for members of the trauma teams.</p> <p>Conclusion: Our study identifies a major shortcoming in the efforts of regionalizing trauma in our region. The findings indicate that training of personnel and protocols for inter-hospital transfer are the major deficiencies from the national trauma system recommendations. Resources for training of personnel partaking in trauma teams and development of inter-hospital transfer agreements should receive immediate attention.</p>
Thu, 26 Jan 2012 00:00:00 GMThttp://hdl.handle.net/1956/66332012-01-26T00:00:00ZRemifentanil as analgesia for labour painhttp://hdl.handle.net/1956/6584
Remifentanil as analgesia for labour pain
Tveit, Tor Oddbjørn
Doctoral thesis
<p>Aims: To collect updated information about pharmacological labour analgesia in Norway, especially
systemic opioids and epidural. Evaluation of efficacy and safety with remifentanil IVPCA
(intravenous patient-controlled analgesia) for pain relief during labour. To compare
remifentanil IVPCAwith epidural analgesia (EDA) regarding efficacy and safety during
labour.</p> <p>Methods: In paper I, two national surveys identified Norwegian labour analgesia methods and changes
during the study period (2005-2008). Paper II is a prospective, observational study of
analgesic efficacy and safety with remifentanil IVPCA. Paper III is a prospective, randomized
controlled trial comparing remifentanil IVPCA with EDA regarding analgesic efficacy and
safety.</p> <p>Results: The surveys in paper I found the frequency of EDA in Norwegian hospitals to be increasing,
but still low (25.9%) compared to other western countries. Nitrous oxide and traditional
systemic opioids, like pethidine, were frequently used. In paper II remifentanil IVPCA was
found to give satisfactory labour analgesia in more than 90% of the parturients with an
average maximal pain reduction of 60%. Maternal oxygen desaturation and sedation were
acceptable, and neonatal data reassuring. In paper III, a randomized controlled trial found
remifentanil IVPCA and EDA to be comparable both regarding analgesic efficacy (pain
reduction) and maternal satisfaction. Remifentanil IVPCA produced more maternal sedation
and oxygen desaturation, neonatal outcome was reassuring in both groups.</p> <p>Conclusions: The frequency of epidural labour analgesia in Norway has increased, but is still relatively low.
Nitrous oxide and traditional systemic opioids are frequently used. The clinical practice seems
conservative, newer short-acting opioids are seldom used for systemic labour analgesia. The
studies on remifentanil IVPCA revealed adequate pain relief, high maternal satisfaction, and
no serious neonatal side effects. There were no differences in analgesic efficacy, maternal satisfaction, and neonatal outcome when comparing remifentanil IVPCA with EDA.
However, remifentanil caused maternal sedation and oxygen desaturation. We recommend the
use of IVPCA remifentanil as labour analgesia instead of traditional opioids as pethidine and
morphine when EDA is not an option. The presence of skilled personnel and close monitoring
is mandatory.</p>
Thu, 18 Apr 2013 00:00:00 GMThttp://hdl.handle.net/1956/65842013-04-18T00:00:00ZSustainability of healthcare improvement: what can we learn from learning theory?http://hdl.handle.net/1956/6473
Sustainability of healthcare improvement: what can we learn from learning theory?
Hovlid, Einar; Bukve, Oddbjørn; Haug, Kjell; Aslaksen, Aslak; Plessen, Christian von
Peer reviewed; Journal article
<p><strong>Background</strong>
Changes that improve the quality of health care should be sustained. Falling back to old, unsatisfactory ways of working is a waste of resources and can in the worst case increase resistance to later initiatives to improve care. Quality improvement relies on changing the clinical system yet factors that influence the sustainability of quality improvements are poorly understood. Theoretical frameworks can guide further research on the sustainability of quality improvements. Theories of organizational learning have contributed to a better understanding of organizational change in other contexts. To identify factors contributing to sustainability of improvements, we use learning theory to explore a case that had displayed sustained improvement.</p>
<p><strong>Methods</strong>
Førde Hospital redesigned the pathway for elective surgery and achieved sustained reduction of cancellation rates. We used a qualitative case study design informed by theory to explore factors that contributed to sustain the improvements at Førde Hospital. The model Evidence in the Learning Organization describes how organizational learning contributes to change in healthcare institutions. This model constituted the framework for data collection and analysis. We interviewed a strategic sample of 20 employees. The in-depth interviews covered themes identified through our theoretical framework. Through a process of coding and condensing, we identified common themes that were interpreted in relation to our theoretical framework.</p>
<p><strong>Results</strong>
Clinicians and leaders shared information about their everyday work and related this knowledge to how the entire clinical pathway could be improved. In this way they developed a revised and deeper understanding of their clinical system and its interdependencies. They became increasingly aware of how different elements needed to interact to enhance the performance and how their own efforts could contribute.</p>
<p><strong>Conclusions</strong>
The improved understanding of the clinical system represented a change in mental models of employees that influenced how the organization changed its performance. By applying the framework of organizational learning, we learned that changes originating from a new mental model represent double-loop learning. In double-loop learning, deeper system properties are changed, and consequently changes are more likely to be sustained.</p>
Fri, 03 Aug 2012 00:00:00 GMThttp://hdl.handle.net/1956/64732012-08-03T00:00:00ZImplementation of a fracture and dislocation registry. Epidemiology and scoring validity of long-bone fractureshttp://hdl.handle.net/1956/6443
Implementation of a fracture and dislocation registry. Epidemiology and scoring validity of long-bone fractures
Meling, Terje
Doctoral thesis
<p>Introduction: The Fracture and Dislocation Registry of Stavanger University
Hospital were initiated 1st of January 2004 to accomplish the request of reliable data
regarding incidence, modes of treatment and outcome of fractures. To ensure good
quality in the registry the data have been consecutively controlled. To prepare the
registry for further research the most important parameter, the classification code was
validated.</p> <p>Method: All inpatient primary and secondary treatments of fractures made at the
operation theatre were classified and reported by the surgeons consecutively. The
most important parameters were; the AO/OTA- and Gustilo/Anderson-classification,
the method of fixation, and the reasons for the reoperations. The surgeons recoded the
fractures during the intra- and inter-rater analyses. A reference code dataset was made
for accuracy assessment.</p> <p>Results: All involved surgeons reported to the registry. Completeness has been
excellent. Approximately 28 % of the long bone fractures that was diagnosed
inhospitally or at the Emergency Department were treated in the operation theatre.
The overall incidence per 100,000 per year was 406 with a 95% confidence interval
(95%CI) of 395–417. The male:female ratio was 2:1 among those <50 years, and 1:3
in those ≥50 years. The accuracy of (four sign of) the AO/OTA classification was for
adult fractures; kappa agreement of 0.68 (95% CI: 0.65–0.71) and for children’s
fractures Κ=0.72 (95% CI: 0.64-0.79) and PA 76%. Fracture type, frequency of the
fracture, and segment fractured significantly influenced accuracy, whereas the
coder’s experience did not.</p> <p>Conclusion: The implementation of the Fracture and Dislocation Registry has been
made successfully. Maintenance of the registry is assured by the controller through
the features of the electronic database program. The classification according to
AO/OTA classification (= Müller classification) seems to be satisfactory reliable. The registry seems to be well prepared for contribution to quality assurance and
improvements in fracture treatment.</p>
Thu, 07 Mar 2013 00:00:00 GMThttp://hdl.handle.net/1956/64432013-03-07T00:00:00ZReliable classification of children’s fractures according to the comprehensive classification of long bone fractures by Müllerhttp://hdl.handle.net/1956/6442
Reliable classification of children’s fractures according to the comprehensive classification of long bone fractures by Müller
Meling, Terje; Harboe, Knut; Enoksen, Cathrine H.; Aarflot, Morten; Arthursson, Astvaldur J.; Søreide, Kjetil
Peer reviewed; Journal article
<p>Background and purpose: Guidelines for fracture treatment and
evaluation require a valid classification. Classifications especially
designed for children are available, but they might lead to reduced
accuracy, considering the relative infrequency of childhood fractures
in a general orthopedic department. We tested the reliability
and accuracy of the Müller classification when used for long bone
fractures in children.</p> <p>Methods: We included all long bone fractures in children
aged < 16 years who were treated in 2008 at the surgical ward
of Stavanger University Hospital. 20 surgeons recorded 232 fractures.
Datasets were generated for intra- and inter-rater analysis,
as well as a reference dataset for accuracy calculations. We present
proportion of agreement (PA) and kappa (K) statistics.
Results For intra-rater analysis, overall agreement (Κ) was
0.75 (95% CI: 0.68–0.81) and PA was 79%. For inter-rater assessment,
K was 0.71 (95% CI: 0.61–0.80) and PA was 77%. Accuracy
was estimated: Κ = 0.72 (95% CI: 0.64–0.79) and PA = 76%.</p> <p>Interpretation: The Müller classification (slightly adjusted
for pediatric fractures) showed substantial to excellent accuracy
among general orthopedic surgeons when applied to long bone
fractures in children. However, separate knowledge about the
child-specific fracture pattern, the maturity of the bone, and the
degree of displacement must be considered when the treatment
and the prognosis of the fractures are evaluated.</p>
Tue, 01 Jan 2013 00:00:00 GMThttp://hdl.handle.net/1956/64422013-01-01T00:00:00ZTherapeutic Hypothermia after Out-of-Hospital Cardiac Arrest - implementation and clinical managementhttp://hdl.handle.net/1956/6284
Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest - implementation and clinical management
Busch, Michael
Doctoral thesis
<p>Background: With the publication of two randomized controlled trials (RCTs) in
2002, therapeutic hypothermia (TH) was re-introduced in postresuscitation care of
comatose out-of-hospital cardiac arrest (OHCA) patients. Many issues, however, were
unresolved, including implementation protocol, cooling technique, clinical
management, implications of TH treatment on prognostic accuracy and therapeutic
benefit in subgroups of OHCA excluded from the initial RCTs. Objectives: We
wanted to study the implementation of therapeutic hypothermia into daily practice,
provide information on clinical management, including differences in cooling
techniques and test application in elderly OHCA patients excluded in earlier trials.</p><p>Subjects: We evaluated the clinical management of adult comatose OHCA patients
who were treated in our ICU (paper I and IV). In paper II we surveyed our intensive
care nursing staff with regard to key nursing aspects of different cooling methods and
devices. In paper III, ICU consultants were assessed on their prognostic approach in
OHCA patients treated with TH.</p><p>Methods: In paper I we retrospectively compared
OHCA patients treated with TH with a historic control group of OHCA patients
fulfilling the TH inclusion criteria. We collected Utstein template data, as well as data
on ICU-and hospital length of stay (LOS), incidence of adverse events, and outcome
at hospital discharge and after one year. In paper II an anonymous survey was
conducted with our intensive care nursing (ICN) staff, assessing ease of application,
hygiene, work load, noise level and visual patient monitoring of four different cooling
methods. In paper III we used a semi-structured telephone interview to conduct a
nation-wide survey of the prognostication approach of comatose OHCA patients
involving timing, methods, involved specialties and rating of prognostic methods. In
paper IV we retrospectively studied outcome variables in all adult OHCA patients
treated with TH in our ICU over a six-year period, who fulfilled the Hypothermia
After Cardiac Arrest study (HACA) criteria with exception of the upper age limit.
Results: With our simple cooling protocol we achieved 100% implementation and
successful attainment of target temperature (TT) in 89% of patients (paper I). However, it took median 7, 5 hours (1-10 h) to reach TT, which was maintained for
median 10 hours (6-19h). Demographics, Utstein template data, ICU and hospital
LOS did not differ significantly between the two groups. Insulin resistance and
hypokalemia were significantly more frequent in the TH group, whereas seizures were
observed more frequent in the normothermia group. The TH group showed
significantly higher rates of survival to hospital discharge (59% vs. 32%, p = 0, 05).
In paper IV we found that although older age influenced outcome, over half of OHCA
patients older than 75 years showed favorable outcome at hospital discharge. The four
cooling methods used in our department differed significantly regarding key nursing
aspects (paper II). Our simple cooling method scored high regarding ease of
application and noise level, but low in work load and hygiene. The CoolGard and
ArticSun systems scored highest in work load and hygiene. Only 53% of ICNs were
satisfied with their initial training and merely 10% felt adequately prepared at the time
when TH was introduced. In paper III we found that even after introduction of TH,
prognostication after OHCA was performed within 48 hours in the majority of
patients. More than one specialty was involved, using mainly clinical neurological
examination (100%), prehospital data (76%), cerebral computer tomography (CCT)
(58%) and electroencephalography (EEG) (52%) findings. Somatosensory evoked
potentials (SSEP) (8%), biochemical markers (8%) and magnetic resonance imaging
(MRI) (8%) only played a minor role. Only one ICU used a standardized protocol.</p><p>Conclusions: Our simple external cooling protocol could be rapidly implemented,
was safe, cheap and feasible, but not optimal with regard to accurate temperature
management (paper I). Key nursing elements differed significantly among available
cooling methods (paper II). Even though age influences outcome, more than half of
our OHCA population older than 75 years showed good outcome. The limitation of
patient eligibility for TH treatment should not be based on age alone (paper IV).
Despite frequent use of TH, prognostication after OHCA was executed early, mainly
based on clinical examination, prehospital data, CCT and EEG results. SSEP seems to
be underused and underrated, whereas the clinical accuracy of CCT, prehospital data
and EEG seems to be overrated (paper III).</p>
Fri, 02 Nov 2012 00:00:00 GMThttp://hdl.handle.net/1956/62842012-11-02T00:00:00ZPrognostication after out-of-hospital cardiac arrest, a clinical surveyhttp://hdl.handle.net/1956/6283
Prognostication after out-of-hospital cardiac arrest, a clinical survey
Busch, Michael; Søreide, Eldar
Peer reviewed; Journal article
<p>Background: Numerous parameters and tests have been proposed for outcome prediction in
comatose out-of-hospital cardiac arrest survivors. We conducted a survey of clinical practice of
prognostication after therapeutic hypothermia (TH) became common practice in Norway.</p><p>Methods: By telephone, we interviewed the consultants who were in charge of the 25 ICUs
admitting cardiac patients using 6 structured questions regarding timing, tests used and medical
specialties involved in prognostication, as well as the clinical importance of the different parameters
used and the application of TH in these patients.</p><p>Results: Prognostication was conducted within 24–48 hours in the majority (72%) of the
participating ICUs.
The most commonly applied parameters and tests were a clinical neurological examination (100%),
prehospital data (76%), CCT (56%) and EEG (52%). The parameters and tests considered to be of
greatest importance for accurate prognostication were prehospital data (56%), neurological
examination (52%), and EEG (20%).
In 76% of the ICUs, a multidisciplinary approach to prognostication was applied, but only one ICU
used a standardised protocol. Therapeutic hypothermia was in routine use in 80% of the surveyed
ICUs.</p><p>Conclusion: Despite the routine use of TH, outcome prediction was performed early and was
mainly based on prehospital information, neurological examination and CCT and EEG evaluation.
Somatosensory evoked potentials appear to be underused and underrated, while the importance
of prehospital data, CCT and EEG to appear to be overrated as methods for making accurate
predictions.
More evidence-based protocols for prognostication in cardiac arrest survivors, as well as additional
studies on the effect of TH on known prognostic parameters are needed.</p>
Mon, 15 Sep 2008 00:00:00 GMThttp://hdl.handle.net/1956/62832008-09-15T00:00:00ZRevisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variableshttp://hdl.handle.net/1956/5564
Revisiting the value of pre-hospital tracheal intubation: an all time systematic literature review extracting the Utstein airway core variables
Lossius, Hans Morten; Sollid, Stephen J. M.; Rehn, Marius; Lockey, David J.
Peer reviewed; Journal article
Introduction: Although tracheal intubation (TI) in the pre-hospital setting is regularly carried out by emergency
medical service (EMS) providers throughout the world, its value is widely debated. Heterogeneity in procedures,
providers, patients, systems and stated outcomes, and inconsistency in data reporting make scientific reports
difficult to interpret and compare, and the majority are of limited quality. To hunt down what is really known
about the value of pre-hospital TI, we determined the rate of reported Utstein airway variables (28 core variables
and 12 fixed-system variables) found in current scientific publications on pre-hospital TI.
Methods: We performed an all time systematic search according to the PRISMA guidelines of Medline and
EMBASE to identify original research pertaining to pre-hospital TI in adult patients.
Results: From 1,076 identified records, 73 original papers were selected. Information was extracted according to an
Utstein template for data reporting from in-the-field advanced airway management. Fifty-nine studies were from
North American EMS systems. Of these, 46 (78%) described services in which non-physicians conducted TI. In 12 of
the 13 non-North American EMS systems, physicians performed the pre-hospital TI. Overall, two were randomised
controlled trials (RCTs), and 65 were observational studies. None of the studies presented the complete set of
recommended Utstein airway variables. The median number of core variables reported was 10 (max 21, min 2, IQR
8-12), and the median number of fixed system variables was 5 (max 11, min 0, IQR 4-8). Among the most
frequently reported variables were “patient category” and “service mission type”, reported in 86% and 71% of the
studies, respectively. Among the least-reported variables were “co-morbidity” and “type of available ventilator”, both
reported in 2% and 1% of the studies, respectively.
Conclusions: Core data required for proper interpretation of results were frequently not recorded and reported in
studies investigating TI in adults. This makes it difficult to compare scientific reports, assess their validity, and
extrapolate to other EMS systems. Pre-hospital TI is a complex intervention, and terminology and study design
must be improved to substantiate future evidence based clinical practice.
Tue, 18 Jan 2011 00:00:00 GMThttp://hdl.handle.net/1956/55642011-01-18T00:00:00ZPatients Referred to a Norwegian Trauma Centre: effect of transfer distance on injury patterns, use of resources and outcomeshttp://hdl.handle.net/1956/5560
Patients Referred to a Norwegian Trauma Centre: effect of transfer distance on injury patterns, use of resources and outcomes
Kristiansen, Thomas; Lossius, Hans Morten; Søreide, Kjetil; Steen, Petter Andreas; Gaarder, Christine; Næss, Pål A.
Peer reviewed; Journal article
Background: Triage and interhospital transfer are central to trauma systems. Few studies have addressed
transferred trauma patients. This study investigated transfers of variable distances to OUH (Oslo University Hospital,
Ullevål), one of the largest trauma centres in Europe.
Methods: Patients included in the OUH trauma registry from 2001 to 2008 were included in the study.
Demographic, injury, management and outcome data were abstracted. Patients were grouped according to
transfer distance: ≤20 km, 21-100 km and > 100 km.
Results: Of the 7.353 included patients, 5.803 were admitted directly, and 1.550 were transferred. The number of
transfers per year increased, and there was no reduction in injury severity during the study period. Seventy-six per
cent of the transferred patients were severely injured. With greater transfer distances, injury severity increased, and
there were larger proportions of traffic injuries, polytrauma and hypotensive patients. With shorter distances,
patients were older, and head injuries and injuries after falls were more common. The shorter transfers less often
activated the trauma team: ≤20 km -34%; 21-100 km -51%; > 100 km -61%, compared to 92% of all directly
admitted patients. The mortality for all transferred patients was 11%, but was unequally distributed according to
transfer distance.
Conclusion: This study shows heterogeneous characteristics and high injury severity among interhospital transfers.
The rate of trauma team assessment was low and should be further examined. The mortality differences should be
interpreted with caution as patients were in different phases of management. The descriptive characteristics
outlined may be employed in the development of triage protocols and transfer guidelines.
Thu, 16 Jun 2011 00:00:00 GMThttp://hdl.handle.net/1956/55602011-06-16T00:00:00ZEffects of first aid training in the kindergarten. A pilot studyhttp://hdl.handle.net/1956/5550
Effects of first aid training in the kindergarten. A pilot study
Bollig, Georg; Myklebust, Anne G.; Østringen, Kristin
Peer reviewed; Journal article
Objective: Children can be the only persons present in an emergency situation. Aim of the study was to evaluate
the effects of a first aid course for 4-5-year-old kindergarten children given by a first aid instructor and kindergarten
teachers.
Methods: A mixed methods approach using both quantitative and qualitative methods was used to investigate
the effects of teaching first aid in the kindergarten in the present study. 10 kindergarten children at the age of 4-5
years were included in a pilot-study, 5 girls and 5 boys. Three of them were four years and seven were five years
old. Two months after completion of the first aid course children were tested in a scenario where the children had
to provide first aid to an unconscious victim after a cycle accident. The next seven months the children were
followed by participant observation.
Results: The findings suggest that 4-5-year-old children are able to learn and apply basic first aid. Tested two
months after course completion 70% of the children assessed consciousness correctly and knew the correct
emergency telephone number; 60% showed correct assessment of breathing and 40% of the participants
accomplished the other tasks (giving correct emergency call information, knowledge of correct recovery position,
correct airway management) correctly. Many of the children showed their capabilities to do so in a first aid
scenario although some participants showed fear of failure in the test scenario. In an informal group testing most
of these children could perform first aid measures, too. Teaching first aid also lead to more active helping
behaviour and increased empathy in the children.
Conclusion: Kindergarten children aged 4-5 years can learn basic fist aid. First aid training should start in the
kindergarten.
Mon, 28 Feb 2011 00:00:00 GMThttp://hdl.handle.net/1956/55502011-02-28T00:00:00ZImplementation of checklists in health care; learning from high-reliability organisationshttp://hdl.handle.net/1956/5531
Implementation of checklists in health care; learning from high-reliability organisations
Thomassen, Øyvind; Espeland, Ansgar; Søfteland, Eirik; Lossius, Hans Morten; Heltne, Jon-Kenneth; Brattebø, Guttorm
Peer reviewed; Journal article
Background: Checklists are common in some medical fields, including surgery, intensive care and emergency
medicine. They can be an effective tool to improve care processes and reduce mortality and morbidity. Despite the
seemingly rapid acceptance and dissemination of the checklist, there are few studies describing the actual process
of developing and implementing such tools in health care. The aim of this study is to explore the experiences
from checklist development and implementation in a group of non-medical, high reliability organisations (HROs).
Method: A qualitative study based on key informant interviews and field visits followed by a Delphi approach.
Eight informants, each with 10-30 years of checklist experience, were recruited from six different HROs.
Results: The interviews generated 84 assertions and recommendations for checklist implementation. To achieve
checklist acceptance and compliance, there must be a predefined need for which a checklist is considered a well
suited solution. The end-users ("sharp-end”) are the key stakeholders throughout the development and
implementation process. Proximity and ownership must be assured through a thorough and wise process. All
informants underlined the importance of short, self-developed, and operationally-suited checklists. Simulation is a
valuable and widely used method for training, revision, and validation.
Conclusion: Checklists have been a cornerstone of safety management in HROs for nearly a century, and are
becoming increasingly popular in medicine. Acceptance and compliance are crucial for checklist implementation in
health care. Experiences from HROs may provide valuable input to checklist implementation in healthcare.
Mon, 03 Oct 2011 00:00:00 GMThttp://hdl.handle.net/1956/55312011-10-03T00:00:00ZCollecting core data in severely injured patients using a consensus trauma template: an international multicentre studyhttp://hdl.handle.net/1956/5521
Collecting core data in severely injured patients using a consensus trauma template: an international multicentre study
Ringdal, Kjetil Gorseth; Lossius, Hans Morten; Jones, Mary J.; Lauritsen, Jens M.; Coats, Timothy J.; Palmer, Cameron S.; Lefering, Rolf; Bartolomeo, Stefano Di; Dries, David J.; Søreide, Kjetil
Peer reviewed; Journal article
Introduction: No worldwide, standardised definitions exist for documenting, reporting and comparing data from
severely injured trauma patients. This study evaluated the feasibility of collecting the data variables of the
international consensus-derived Utstein Trauma Template.
Methods: Trauma centres from three different continents were invited to submit Utstein Trauma Template core
data during a defined period, for up to 50 consecutive trauma patients. Directly admitted patients with a New
Injury Severity Score (NISS) equal to or above 16 were included. Main outcome variables were data completeness,
data differences and data collection difficulty.
Results: Centres from Europe (n = 20), North America (n = 3) and Australia (n = 1) submitted data on 965 patients,
of whom 783 were included. Median age was 41 years (interquartile range (IQR) 24 to 60), and 73.1% were male.
Median NISS was 27 (IQR 20 to 38), and blunt trauma predominated (91.1%). Of the 36 Utstein variables, 13 (36%)
were collected by all participating centres. Eleven (46%) centres applied definitions of the survival outcome variable
that were different from those of the template. Seventeen (71%) centres used the recommended version of the
Abbreviated Injury Scale (AIS). Three variables (age, gender and AIS) were documented in all patients.
Completeness > 80% was achieved for 28 variables, and 20 variables were > 90% complete.
Conclusions: The Utstein Template was feasible across international trauma centres for the majority of its data
variables, with the exception of certain physiological and time variables. Major differences were found in the
definition of survival and in AIS coding. The current results give a clear indication of the attainability of information
and may serve as a stepping-stone towards creation of a European trauma registry.
Wed, 12 Oct 2011 00:00:00 GMThttp://hdl.handle.net/1956/55212011-10-12T00:00:00ZMaturation of monocyte derived dendritic cells with OK432 boosts IL-12p70 secretion and conveys strong T-cell responseshttp://hdl.handle.net/1956/5486
Maturation of monocyte derived dendritic cells with OK432 boosts IL-12p70 secretion and conveys strong T-cell responses
Hovden, Arnt-Ove; Karlsen, Marie; Jonsson, Roland; Aarstad, Hans Jørgen; Appel, Silke
Peer reviewed; Journal article
Background: Design of tumour specific immunotherapies using the patients’ own dendritic cells (DC) is a fast
advancing scientific field. The functional qualities of the DC generated in vitro are critical, and today’s gold
standard for maturation is a cytokine cocktail consisting of IL-1b, IL-6, TNF-a and PGE2 generating cells lacking IL-
12p70 production. OK432 is an immunotherapeutic agent derived from killed Streptococcus pyogenes that has been
used clinically to treat malignant and benign neoplasms for decades.
Methods: In this study, we analysed the effects of OK432 on DC maturation, DC migration, cytokine and
chemokine secretion as well as T-cell stimulatory capacity, and compared it to the cytokine cocktail alone and
combinations of OK432 with the cytokine cocktail.
Results: OK432 induced a marked up-regulation of CD40 on the cell surface as well as a strong inflammatory
response from the DC with significantly more secretion of 19 different cytokines and chemokines compared to the
cytokine cocktail. Interestingly, secretion of IL-15 and IL-12p70 was detected at high concentrations after
maturation of DC with OK432. However, the OK432 treated DC did not migrate as well as DC treated with cytokine
cocktail in a transwell migration assay. During allogeneic T-cell stimulation OK432 treated DC induced proliferation
of over 50 percent of CD4 and 30 percent of CD8 T-cells for more than two cell divisions, whereas cytokine
cocktail treated DC induced proliferation of 12 and 11 percent of CD4 and CD8 T-cells, respectively.
Conclusions: The clinically approved compound OK432 has interesting properties that warrants its use in DC
immunotherapy and should be considered as a potential immunomodulating agent in cancer immunotherapy.
Wed, 05 Jan 2011 00:00:00 GMThttp://hdl.handle.net/1956/54862011-01-05T00:00:00ZThe top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaborationhttp://hdl.handle.net/1956/5452
The top five research priorities in physician-provided pre-hospital critical care: a consensus report from a European research collaboration
Fevang, Espen; Lockey, David J.; Thompson, Julian; Lossius, Hans Morten
Peer reviewed; Journal article
Background: Physician-manned emergency medical teams supplement other emergency medical services in some
countries. These teams are often selectively deployed to patients who are considered likely to require critical care
treatment in the pre-hospital phase. The evidence base for guidelines for pre-hospital triage and immediate
medical care is often poor. We used a recognised consensus methodology to define key priority areas for research
within the subfield of physician-provided pre-hospital critical care.
Methods: A European expert panel participated in a consensus process based upon a four-stage modified nominal
group technique that included a consensus meeting.
Results: The expert panel concluded that the five most important areas for further research in the field of
physician-based pre-hospital critical care were the following: Appropriate staffing and training in pre-hospital critical
care and the effect on outcomes, advanced airway management in pre-hospital care, definition of time windows
for key critical interventions which are indicated in the pre-hospital phase of care, the role of pre-hospital
ultrasound and dispatch criteria for pre-hospital critical care services.
Conclusion: A modified nominal group technique was successfully used by a European expert group to reach
consensus on the most important research priorities in physician-provided pre-hospital critical care.
Thu, 13 Oct 2011 00:00:00 GMThttp://hdl.handle.net/1956/54522011-10-13T00:00:00ZMagnetic resonance imaging of craniovertebral structures: clinical significance in cervicogenic headacheshttp://hdl.handle.net/1956/5449
Magnetic resonance imaging of craniovertebral structures: clinical significance in cervicogenic headaches
Knackstedt, Heidi; Kråkenes, Jostein; Bansevicius, Dalius; Russell, Michael Bjørn
Peer reviewed; Journal article
This paper aims to investigate the relevance of
morphological changes in the main stabilizing structures of
the craniocervical junction in persons with cervicogenic
headache (CEH). A case control study of 46 consecutive
persons with CEH, 22 consecutive with headache attributed
to whiplash associated headache (WLaH) and 19 consecutive
persons with migraine. The criteria of the Cervicogenic
Headache International Study Group (CHISG) were used for
diagnosing CEH; otherwise the criteria of the International
Classification of Headache Disorders (ICHD II) were
applied. All participants had a clinical interview, and physical
and neurological examination. Proton weighted magnetic
resonance imaging (MRI) of the craniovertebral
junction, and the alar and transverse ligaments were evaluated
and blinded to clinical information. The MRI of the
craniovertebral and the cervical junctions, the alar and
transverse ligaments disclosed no significant differences
between those with CEH, WLaH and or migraine. The site of
CEH pain was not correlated with the site of signal intensity
changes of the alar and transverse ligaments. In fact, very few
had moderate or severe signal intensity changes in their
ligaments. MRI shows no specific changes of cervical discs
or craniovertebral ligaments in CEH.
Tue, 27 Sep 2011 00:00:00 GMThttp://hdl.handle.net/1956/54492011-09-27T00:00:00ZExercise-induced laryngeal obstruction. Diagnostic procedures and therapyhttp://hdl.handle.net/1956/5337
Exercise-induced laryngeal obstruction. Diagnostic procedures and therapy
Maat, Robert Christiaan
Doctoral thesis
Introduction: Exercise-induced inspiratory stridor (EllS) is not uncommon in adolescents. lt can be caused by airflow obstruction at different levels of the airways but most often at the laryngeal level. Although the larynx may function perfectly normally during quiet breathing, obstruction of airflow through the larynx can cause respiratory distress and stridor during exercise. ln the literature, there is confusion over the terminology used for this phenomenon. One of the more recent terms, exercise- induced laryngeal obstruction (ElLO) has the advantage that previous terms can be included into its framework. Laryngeal obstruction typically induces inspiratory stridor as opposed to asthma causing expiratory wheeze. Still, these conditions are all too
often mixed up, and maltreatment can be a consequence. ln order to ease the differentiation between these conditions, a setup for continuous laryngoscopy during exercise had been established prior to the commencement of this work (Heimdal et al.,
2006). Aims: The first aim of this thesis was to apply the continuous laryngoscopy exercise (CLE)-test on a larger series of patients experiencing exercise-induced inspiratory stridor (EllS). Clinical application of the test uncovered a need for a more objective evaluation of findings, and therefore the second aim was to develop a scoring scheme that could be used to grade the level and severity of laryngeal obstruction and to assess the reliability and validity of this CLE-test score. We experienced that some patients had serious problems with respiratory distress during exercise and therefore we offered surgical treatment to patients selected by clinical criteria; i.e. if the patients experienced severe distress during exercise, were highly motivated for surgical treatment in order to reduce symptoms, and we could observe a severe obstruction of the laryngeal inlet during the CLE-test. The third aim was therefore to use the CLE-test in order to reveal the effect of surgical treatment on the laryngeal motion and symptoms. As most ElLO patients are teenagers, one could hypothesise that a natural development and enlargement of the larynx during growth would reduce the laryngeal obstruction during exercise. The fourth aim of this thesis was therefore to assess the natural course of ElLO and to assess the long term effect of surgical treatment of supraglottic ElLO.
Methods: The CLE-test was performed according to the description by Heimdal and co-workers (2006). Video and sound recordings were edited into new data files and could thereby be reviewed in a random order without any clinical information in order to secure a best possible objective assessment. Additional information about symptoms was revealed by questionnaires and visual analogue scores (VAS). ln the follow-up study, change in symptoms of exercise-induced breathing distress, level of activity, and the impact of symptoms on daily life activity was addressed in questionnaires sent by mail. All surgically treated patients and selected patients from the initial part of study were invited to perform a second CLE-test.
Results: ln the first study, the CLE-test turned out to be feasible in order to reveal level and severity of laryngeal obstruction in ElLO patients. We observed that the larynx could be obstructed only at the supraglottic level but most often in combination with obstruction also at the glottic level. The latter was rarely found to be the sole cause of EllS. When CLE-scores of laryngeal obstruction were evaluated in the second study, inter- and intra-observer agreement was moderate to very good. The test was found to be interpretable and also valid as scores were significantly correlated with the severity of respiratory distress symptoms when assessed both by the patients and by observers. The third study included l0 patients for surgery according to the clinical criteria. The patients reported a better ability to breathe while exercising, after surgical treatment, as revealed by VAS scores. Postoperatively, the CLE-test showed an increased abduction of the supraglottic structures during both moderate and maximal exercise. The fourth study included; re-examination of l4 patients, initially tested when teenagers, with a second CLE-test at adult age; a re-examination of l9 of 24 surgically treated patients and; follow-up concerning symptoms of 73 of the 94 patients invited to the study. This study showed that most subjects experienced symptom relief during the observation time, but more so in the surgically treated than untreated patients. Comparison of l9 pre- and postoperative CLE-tests showed a significant improvement in the ability to keep the larynx open, while exercising, in the surgically treated group. On the contrary, little change was observed in laryngeal motion in l4 re-tested, untreated patients. Concluding remarks: We conclude that exercise-induced laryngeal obstruction can be visualized by the CLE-test and that the obstruction of the larynx in ElLO patients is most often due to an inward rotation of the aryepiglottic folds, frequently followed by
a narrowing of the glottic space, and seldom solely due to glottic adduction. ln some cases, major distress and panic reactions can be the endpoint of this phenomenon. The severity of obstruction can be graded by the CLE-score in a reliable and valid manner. Surgery of exercise-induced laryngeal obstruction can be an adequate treatment in strictly selected cases, depending of severity of symptoms, degree of obstruction, and motivation of the patient. EllS due to ElLO does not seem to recover spontaneously in youngsters. Reduced physical activity may give the impression that the laryngeal function has improved.
Thu, 08 Dec 2011 00:00:00 GMThttp://hdl.handle.net/1956/53372011-12-08T00:00:00ZCognitive impairments after critical illness. Methodology, incidences and consequenceshttp://hdl.handle.net/1956/5268
Cognitive impairments after critical illness. Methodology, incidences and consequences
Torgersen, Johan
Doctoral thesis
Brain dysfunction describes the wide range of alterations in brain function from
persistent vegetative state to minor cognitive impairments. It has become evident that
brain dysfunctions that arise during an intensive care unit (ICU) stay are associated
with mortality, morbidity, post-ICU functional status and rehabilitation. Brain
dysfunction in ICU patients is therefore of major interest both in clinical practice and
research.
Cognitive impairment is one of several types of brain dysfunctions that may become
evident after critical illness. The aims of this thesis were to document the incidences
of cognitive dysfunction after critical illness, to investigate the post-ICU development
and effects of cognitive functions and, if possible, to point out etiological and
predisposing factors for such impairment.
To achieve this, we needed a neuropsychological approach to our patients. We chose
to use the Cambridge Neuropsychological Test Automated Battery (CANTAB) as our
method for evaluating cognitive function. CANTAB is a semi-automated
neuropsychological test battery applied on a laptop PC. The program contains
integrated normal reference population scores, which facilitate description of the
tested patients’ level of cognitive function and the statistical handling of the results.
CANTAB can be administered in an every day setting by non-specialised personnel.
Tue, 22 Nov 2011 00:00:00 GMThttp://hdl.handle.net/1956/52682011-11-22T00:00:00ZBenign external hydrocephalus: a review, with emphasis on managementhttp://hdl.handle.net/1956/5247
Benign external hydrocephalus: a review, with emphasis on management
Zahl, Sverre Morten; Egge, Arild; Helseth, Eirik; Wester, Knut
Peer reviewed; Journal article
Benign external hydrocephalus in infants, characterized
by macrocephaly and typical neuroimaging
findings, is considered as a self-limiting condition and
is therefore rarely treated. This review concerns all
aspects of this condition: etiology, neuroimaging, symptoms
and clinical findings, treatment, and outcome, with
emphasis on management. The review is based on a
systematic search in the Pubmed and Web of Science
databases. The search covered various forms of hydrocephalus,
extracerebral fluid, and macrocephaly. Studies
reporting small children with idiopathic external hydrocephalus
were included, mostly focusing on the studies
reporting a long-term outcome. A total of 147 studies are
included, the majority however with a limited methodological
quality. Several theories regarding pathophysiology
and various symptoms, signs, and clinical findings
underscore the heterogeneity of the condition. Neuroimaging
is important in the differentiation between
external hydrocephalus and similar conditions. A transient
delay of psychomotor development is commonly
seen during childhood. A long-term outcome is scarcely
reported, and the results are varying. Although most
children with external hydrocephalus seem to do well
both initially and in the long term, a substantial number
of patients show temporary or permanent psychomotor
delay. To verify that this truly is a benign condition, we
suggest that future research on external hydrocephalus
should focus on the long-term effects of surgical
treatment as opposed to conservative management.
Tue, 07 Jun 2011 00:00:00 GMThttp://hdl.handle.net/1956/52472011-06-07T00:00:00ZTrends in Diagnosis and Surgical Management of Patients with Perforated Peptic Ulcerhttp://hdl.handle.net/1956/5241
Trends in Diagnosis and Surgical Management of Patients with Perforated Peptic Ulcer
Thorsen, Kenneth; Glomsaker, Tom Birger; Meer, Andreas von; Søreide, Kjetil; Søreide, Jon Arne
Peer reviewed; Journal article
Introduction While the laparoscopic treatment of perforated peptic ulcers (PPU) has been shown to be feasible and safe, its
implementation into routine clinical practice has been slow. Only a few studies have evaluated its overall utility. The aim of
this study was to investigate changes in surgical management of PPU and associated outcomes.
Material and Methods The study was a retrospective, single institution, population-based review of all patients undergoing
surgery for PPU between 2003 and 2009. Patient demographics, diagnostic evaluation, management, and outcomes were
evaluated.
Results Included were 114 patients with a median age of 67 years (range, 20–100). Women comprised 59% and were older
(p<0.001), had more comorbidities (p=0.002), and had a higher Boey risk score (p=0.036) compared to men. Perforation
location was gastric/pyloric in 72% and duodenal in 28% of patients. Pneumoperitoneum was diagnosed by plain abdominal
x-ray in 30 of 41 patients (75%) and by abdominal computerized tomography (CT) in 76 of 77 patients (98%; p<0.001).
Laparoscopic treatment was initiated in 48 patients (42%) and completed in 36 patients (75% of attempted cases).
Laparoscopic treatment rate increased from 7% to 46% during the study period (p=0.02). Median operation time was
shorter in patients treated via laparotomy (70 min) compared to laparoscopy (82 min) and those converted from laparoscopy
to laparotomy (105 min; p=0.017). Postoperative complications occurred in 56 patients (49%). Overall 30-day
postoperative mortality was 16%. No statistically significant differences were found in morbidity and mortality between
open versus laparoscopic repair.
Conclusion This study demonstrates an increased use of CT as the primary diagnostic tool for PPU and of laparoscopic
repair in its surgical treatment. These changes in management are not associated with altered outcomes.
Fri, 13 May 2011 00:00:00 GMThttp://hdl.handle.net/1956/52412011-05-13T00:00:00ZPatient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter studyhttp://hdl.handle.net/1956/5226
Patient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter study
Larssen, Lene; Medhus, Asle W.; Hjermstad, Marianne J.; Kørner, Hartwig; Glomsaker, Tom Birger; Søberg, Taran; Gleditsch, Dagfinn; Hovde, Øistein; Nesbakken, Arild; Tholfsen, Jan K.; Skreden, Knut; Hauge, Truls
Peer reviewed; Journal article
Background The clinical effect of stent treatment has
been evaluated by mainly physicians; only a limited
number of prospective studies have used patient-reported
outcomes for this purpose. The aim of this work was to
study the clinical effect of self-expanding metal stents in
treatment of malignant gastrointestinal obstructions, as
evaluated by patient-reported outcomes, and compare the
rating of the treatment effect by patients and physicians.
Methods Between November 2006 and April 2008, 273
patients treated with SEMS for malignant GI and biliary
obstructions were recruited from nine Norwegian hospitals.
Patients and physicians assessed symptoms independently
at the time of treatment and after 2 weeks using the
European Organisation for Research and Treatment of
Cancer (EORTC) QLQ-C30 questionnaire supplemented
with specific questions related to obstruction.
Results A total of 162 patients (99 males; median
age = 72 years) completed both assessments and were
included in the study. A significant improvement in the
mean global health score was observed after 2 weeks (from
9 to 18 on a 0–100 scale, P\0.03) for all stent locations. Both patients and physicians reported a significant reduction
in all obstruction-related symptoms ([20 on the 0–100
scale, P\0.006) after SEMS treatment. The physicians
reported a larger mean improvement in symptoms than did
the patients, mainly because they reported more severe
symptoms before treatment.
Conclusion SEMS treatment is effective in relieving
symptoms of malignant GI and biliary obstruction, as
reported by patients and physicians. The physicians, however,
reported a larger reduction in obstructive symptoms
than did the patients. A prospective assessment of patientreported
outcomes is important in evaluating SEMS
treatment.
Wed, 13 Apr 2011 00:00:00 GMThttp://hdl.handle.net/1956/52262011-04-13T00:00:00ZGene expression profiling of meningiomas: current status after a decade of microarray-based transcriptomic studieshttp://hdl.handle.net/1956/5216
Gene expression profiling of meningiomas: current status after a decade of microarray-based transcriptomic studies
Aarhus, Mads; Lund-Johansen, Morten; Knappskog, Per
Peer reviewed; Journal article
Purpose This article provides a review of the transcriptomic
expression profiling studies that have been performed on
meningiomas so far. We discuss some future prospects and
challenges ahead in the field of gene expression profiling.
Methods We performed a systematic search in the PubMed
and EMBASE databases in May 2010 using the following
search terms alone or in combination: “meningioma”,
“microarray analysis”, “oligonucleotide array sequence
analysis”, or “gene expression profiling”. Only original
research articles in English that had used RNA hybridized
to high-resolution microarray chips to generate gene
expression profiles were included.
Results We identified 13 articles matching the inclusion
criteria. All studies had been performed during the last decade.
Conclusions The main results of the studies can be grouped
in three categories: (1) several groups have identified
meningioma-specific genes and genes associated with the
three WHO grades, and the main histological subtypes of
grade I meningiomas; (2) one publication has shown that
the general transcription profile of samples of all WHO
grades differs in vivo and in vitro; (3) one report provides
evidence that microarray technology can be used in an
automated fashion to classify tumors. Due to lack of
consensus on how microarray data are presented, possible
general trends found across the studies are difficult to
extract. This could obstruct the discovery of important
genes and pathways universally involved in meningioma
biology.
Fri, 14 Jan 2011 00:00:00 GMThttp://hdl.handle.net/1956/52162011-01-14T00:00:00ZExtensor tendon release in tennis elbow: results and prognostic factors in 80 elbowshttp://hdl.handle.net/1956/5205
Extensor tendon release in tennis elbow: results and prognostic factors in 80 elbows
Solheim, Eirik; Hegna, Janne; Øyen, Jannike
Peer reviewed; Journal article
Purpose The objectives of this study were to evaluate the
results in the outpatient treatment of recalcitrant lateral
epicondylitis with release of the common extensor origin
according to Hohmann and to determine any prognostic
factors.
Methods Eighty tennis elbows in 77 patients with a
characteristic history of activity-related pain at the lateral
epicondyle interfering with the activities of daily living
refractory to conservative care for at least 6 months and a
confirmatory physical examination were included. Clinical
outcome was evaluated using the QuickDASH score system.
Data were collected before the operation and at the
medians of 18 months (range 6–36 months; short term) and
4 years (range 3–6 years; medium term) postoperatively.
Results The mean QuickDASH was improved both at the
short- and the medium-term follow-ups and did not change
significantly between the follow-ups. At the final followup,
the QuickDASH was improved in 78 out of 80 elbows
and 81% was rated as excellent or good (QuickDASH\40
points). We found a weak correlation between residual
symptoms (a high QuickDASH score) at the final follow-up
and high level of baseline symptoms (r = 0.388), acute
occurrence of symptoms (r = 0.362), long duration of
symptoms (r = 0.276), female gender (r = 0.269) and
young age (r = 0.203), whereas occurrence in dominant
arm, a work-related cause or strenuous work did not correlate
significantly with the outcome.
Conclusion Open lateral extensor release performed as
outpatient surgery results in improved clinical outcome at
both short- and medium-term follow-ups with few complications.
High baseline disability, sudden occurrence of
symptoms, long duration of symptoms, female gender and
young age were found to be weak predictors of poor
outcome.
Wed, 16 Mar 2011 00:00:00 GMThttp://hdl.handle.net/1956/52052011-03-16T00:00:00ZOverall survival after resection for colon cancer in a national cohort study was adversely affected by TNM stage, lymph node ratio, gender, and old agehttp://hdl.handle.net/1956/5202
Overall survival after resection for colon cancer in a national cohort study was adversely affected by TNM stage, lymph node ratio, gender, and old age
Storli, Kristian E.; Søndenaa, Karl; Bukholm, Ida Rashida Khan; Nesvik, Idunn; Bru, Tore; Furnes, Bjørg; Hjelmeland, Bjarte; Iversen, Knut B.; Eide, Geir Egil
Peer reviewed; Journal article
Background A national surveillance program of colon cancer
treatment was introduced in 2007. We examined prognostic
factors for colon cancer operated in 2000 with an aim of
improving survival in the new program and a special focus on
the merit of lymph node yield.
Methods A cohort of 269 patients, 152 women (56.5%), with
a mean age of 71 years, was operated for colon cancer in 2000
at three teaching hospitals and followed up for 7 years.
Results Overall 5-year survival was 58.0%, and overall
hospital mortality was 5.2%, with 4.5% in elective cases
and 12.5% after urgent surgery. In only 41.1% of the
specimens were 12 or more lymph nodes retrieved, but this
did not affect survival in the combined cohort, although one
of the hospitals achieved a significantly better result with a
harvest of 12 or more lymph nodes. In a multivariate
analysis, old age, gender, a high lymph node ratio (LNR) at
stage III, and tumor–node–metastasis stage were adverse
factors for survival.
Conclusions The operative mortality was high and should
be reassessed. The lymph node count did not have a
significant impact on outcome overall, whereas the LNR
proved significant for stage III. A prospective protocol
using overall lymph node yield as a surrogate measure for
more radical surgery, nevertheless, seems warranted to
improve the lymph node harvest according to international
recommendations.
Thu, 12 May 2011 00:00:00 GMThttp://hdl.handle.net/1956/52022011-05-12T00:00:00ZPostural control in a simulated saturation dive to 240 msw.http://hdl.handle.net/1956/4842
Postural control in a simulated saturation dive to 240 msw.
Goplen, Frederik Kragerud; Aasen, T. B.; Nordahl, Stein Helge G.
Journal article; Peer reviewed
INTRODUCTION: There is evidence that increased ambient pressure
causes an increase in postural sway. This article documents postural sway at pressures not previously studied
and discusses possible mechanisms. METHODS: Eight subjects participated in a dry chamber dive to 240
msw (2.5 MPa) saturation pressure. Two subjects were excluded due to unilateral caloric weakness before
the dive. Postural sway was measured on a force platform. The path length described by the center of
pressure while standing quietly for 60 seconds was used as test variable. Tests were repeated 38 times in four
conditions: with eyes open or closed, while standing on bare platform or on a foam rubber mat. RESULTS:
Upon reaching 240 msw, one subject reported vertigo, disequilibrium and nausea, and in all subjects, mean
postural sway increased 26% on bare platform with eyes open (p < 0.05) compared to predive values. There
was no significant improvement in postural sway during the bottom phase, but a trend was seen toward
improvement when the subjects were standing with eyes closed on foam rubber (p = 0.1). Postural sway
returned to predive values during the decompression phase. DISCUSSION: Postural imbalance during deep
diving has been explained previously as HPNS possibly including a specific effect on the vestibulo-ocular
reflex. Although vertigo and imbalance are known to be related to compression rate, this study shows that
there remains a measurable increase in postural sway throughout the bottom phase at 240 msw, which seems
to be related to absolute pressure.
Mon, 01 Jan 2007 00:00:00 GMThttp://hdl.handle.net/1956/48422007-01-01T00:00:00ZEffects of diving on hearing and balancehttp://hdl.handle.net/1956/4841
Effects of diving on hearing and balance
Goplen, Frederik Kragerud
Doctoral thesis
Diving has profound effects on the human body including the inner ear, which
contains the organs of hearing and balance. Ear injury is the most common medical
problem in diving. The aim of this work was to explore the short and long-term
effects of diving on hearing and balance through a simulated deep saturation dive and
two epidemiological studies on commercial divers.
The first study explored short-term effects of absolute pressure on the body. The
high-pressure neurological syndrome (HPNS) occurs at pressures exceeding 150
msw. The symptoms include tremors, decreased psychomotor performance, dizziness,
nausea and drowsiness, and there is a tendency for adaptation, since many of the
symptoms disappear quickly when pressure is held constant. In this study we
measured postural stability in a simulated saturation dive in helium-oxygen to 240
msw, which lasted for 19 days. Eight subjects participated. Postural balance was
measured 152 times during the dive by means of a force platform (static
posturography). In spite of a long compression phase (>20 h) including three stops for
adaptation, postural instability was observed throughout the bottom phase. There was
no significant adaptation, but balance normalized during the decompression. Postural
instability therefore seems to be related not only to compression rate, but also to
absolute pressure. This could indicate that posturography is more sensitive than other
methods in detecting HPNS.
The second study included 230 offshore divers who had been working on the
Norwegian continental shelf before 1990. Most of them had retired from diving. The
main finding was that these divers had more vestibular symptoms, such as dizziness,
vertigo and disequilibrium than age-matched controls, and that they also had more
postural instability as measured by static posturography. The finding is important,
since these symptoms often lead to decreased quality of life. The symptoms were
strongly associated with a previous history of decompression sickness, which is one
of the major causes of morbidity in professional divers. The third study included 67 young subjects attending a basic course for professional
divers. They were examined at the course, after three and six years. Transient
dizziness or vertigo was a common experience while diving, and the possible causes
are discussed in this thesis. We found no long-term effects of frequent diving per se
on balance or subjective disequilibrium. There were no cases of inner ear barotrauma
or inner ear decompression sickness during follow-up. However, there was a
progressive deterioration of hearing thresholds at 4 kHz, a frequency commonly
affected by noise. There was also an increase in the prevalence of subjective hearing
difficulties. Both were associated with occupational noise exposure, but not
significantly with the amount of diving. We therefore concluded that noise was the
most important cause of hearing loss in this diver group.
Summing up the results from the three studies, long-term effects were found on both
hearing and balance, which were associated with noise and decompression sickness
respectively. No long-term effects were found in association with frequent diving per
se, however transient postural instability appears to be a feature of deep diving, and
was found to last through the bottom phase even after a slow compression.
Fri, 10 Jun 2011 00:00:00 GMThttp://hdl.handle.net/1956/48412011-06-10T00:00:00ZOsteoporosis as a Risk Factor for Distal Radial Fractures. A Case-Control Studyhttp://hdl.handle.net/1956/4765
Osteoporosis as a Risk Factor for Distal Radial Fractures. A Case-Control Study
Øyen, Jannike; Brudvik, Christina; Gjesdal, Clara Gram; Tell, Grethe Seppola; Lie, Stein Atle; Hove, Leiv M.
Journal article; Peer reviewed
Background: Distal radial fractures occur earlier in life than hip and spinal fractures and may be the first sign of
osteoporosis. The aims of this case-control study were to compare the prevalence of osteopenia and osteoporosis
between female and male patients with low-energy distal radial fractures and matched controls and to investigate whether
observed differences in bone mineral density between patients and controls could be explained by potential confounders.
Methods: Six hundred and sixty-four female and eighty-five male patients who sustained a distal radial fracture, and 554
female and fifty-four male controls, were included in the study. All distal radial fractures were radiographically confirmed.
Bone mineral density was assessed with use of dual x-ray absorptiometry at the femoral neck, total hip (femoral neck,
trochanter, and intertrochanteric area), and lumbar spine (L2-L4). A self-administered questionnaire provided information
on health and lifestyle factors.
Results: The prevalence of osteoporosis was 34% in female patients and 10% in female controls. The corresponding values
were 17% in male patients and 13% in male controls. In the age group of fifty to fifty-nine years, 18% of female patients and 5%
of female controls had osteoporosis. In the age group of sixty to sixty-nine years, the corresponding values were 25% and 7%,
respectively. In adjusted conditional logistic regression analyses, osteopenia and osteoporosis were significantly associated
with distal radial fractures in women. Osteoporosis was significantly associated with distal radial fractures in men.
Conclusions: The prevalence of osteoporosis in patients with distal radial fractures is high compared with that in control
subjects, and osteoporosis is a risk factor for distal radial fractures in both women and men. Thus, patients of both sexes
with an age of fifty years or older who have a distal radial fracture should be evaluated with bone densitometry for the
possible treatment of osteoporosis.
Sat, 01 Jan 2011 00:00:00 GMThttp://hdl.handle.net/1956/47652011-01-01T00:00:00ZLow-energy fracture of the distal radius in middleaged and elderly Norwegian women and men. Topics related to osteoporosis, fracture risk and vitamin Dhttp://hdl.handle.net/1956/4764
Low-energy fracture of the distal radius in middleaged and elderly Norwegian women and men. Topics related to osteoporosis, fracture risk and vitamin D
Øyen, Jannike
Doctoral thesis
Introduction: Low-energy distal radius fractures normally occur earlier in life than hip and spine fractures
and may be the first presentation of osteoporosis. Few studies have addressed the association
between distal radius fracture and osteoporosis. Vitamin D inadequacy is associated with an
increased risk of hip fractures, but the association with distal radius fractures has not been
explored. Aims: The aims of this study were to determine the prevalence of patients with a distal radius
fracture in need of osteoporosis treatment according to certain guidelines, calculate the
subsequent fracture risk, and to investigate the association between distal radius fracture and
osteoporosis and vitamin D inadequacy. Materials and methods: Paper I is a cross-sectional study of 1,576 female and 218 male distal radius fracture patients
aged 50 years and older from Bergen, Kristiansand and Skien. Papers II and III are casecontrol
studies based on the 664 female and 85 male patients from Bergen and 554 female
and 54 male controls from the same area.
Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DXA). A
self-administered questionnaire included information on health and lifestyle factors. A
fracture risk assessment tool (FRAX®) was used to calculate the 10-year fracture risk. Serum
25-hydroxyvitamin D (s-25(OH)D) was analysed. Results: The prevalence of T-score −2.0 and −2.5 standard deviation (SD) at femoral neck was
51% and 31% in female and 38% and 20% in male distal radius fracture patients,
respectively (Paper I). The 10-year FRAX® estimated hip fracture risk in all female and male
patients was 9% and 6%, respectively. The corresponding figures for female and male patients with osteoporosis were 18% and 16%, respectively. A large proportion of distal
radius fracture patients with a high 10-year fracture risk did not have osteoporosis.
In the matched case-control study (Paper II) the prevalence of osteoporosis was 34% in
female patients compared to 10% in female controls. Among men the figures were 17% and
13%, respectively. After adjustment for confounding factors by conditional logistic
regression, osteoporosis was significantly associated with distal radius fractures in both
women and men.
The mean s-25(OH)D was 67 nmol/L in female patients and 79 nmol/L in female controls
(p<0.001) (Paper III). In men the corresponding figures were 65 and 77 nmol/L (p=0.017),
respectively. In adjusted conditional logistic regression analyses, s-25(OH)D < 50 nmol/L,
and 50-75 nmol/L were associated with distal radius fractures in women, and s-25(OH)D <
50 nmol/L was associated with distal radius fractures in men. Conclusions: A high proportion of the distal radius fracture patients had osteoporosis compared to
matched controls. However, a large proportion of the patients were not diagnosed with
osteoporosis, and many of them had a high FRAX® score without having osteoporosis.
Furthermore, osteoporosis and vitamin D inadequacy were associated with distal radius
fractures. Thus, our results indicate that patients aged 50 years and older with a low-energy
distal radius fracture should be referred to bone densitometry for measurement of BMD, and
be evaluated for potential risk factors, as well as for vitamin D inadequacy.
Fri, 25 Feb 2011 00:00:00 GMThttp://hdl.handle.net/1956/47642011-02-25T00:00:00ZMicroarray-based gene expression profiling and DNA copy number variation analysis of temporal fossa arachnoid cystshttp://hdl.handle.net/1956/4706
Microarray-based gene expression profiling and DNA copy number variation analysis of temporal fossa arachnoid cysts
Aarhus, Mads; Helland, Christian Andre; Lund-Johansen, Morten; Wester, Knut; Knappskog, Per
Peer reviewed; Journal article
Background
Intracranial arachnoid cysts (AC) are membranous sacs filled with CSF-like fluid that are commonly found in the temporal fossa. The majority of ACs are congenital. Typical symptoms are headache, dizziness, and dyscognition. Little is known about genes that contribute to the formation of the cyst membranes.
Methods
In order to identify differences in gene expression between normal arachnoid membrane (AM) and cyst membrane, we have performed a high-resolution mRNA microarray analysis. In addition we have screened DNA from AC samples for chromosomal duplications or deletions using DNA microarray-based copy number variation analysis.
Results
The transcriptome consisting of 33096 gene probes showed a near-complete similarity in expression between AC and AM samples. Only nine genes differed in expression between the two tissues: ASGR1, DPEP2, SOX9, SHROOM3, A2BP1, ATP10D, TRIML1, NMU were down regulated, whereas BEND5 was up regulated in the AC samples. Three of the AC samples had unreported human DNA copy number variations, all DNA gains.
Conclusions
Extending results of previous anatomical studies, the present study has identified a small subset of differentially expressed genes and DNA alterations in arachnoid cysts compared to normal arachnoid membrane.
Fri, 26 Feb 2010 00:00:00 GMThttp://hdl.handle.net/1956/47062010-02-26T00:00:00ZHigh-dose chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer: a retrospective cohort studyhttp://hdl.handle.net/1956/4686
High-dose chemoradiotherapy followed by surgery versus surgery alone in esophageal cancer: a retrospective cohort study
Hurmuzlu, Meysan; Øvrebø, Kjell; Monge, Odd R.; Smaaland, Rune; Wentzel-Larsen, Tore; Viste, Asgaut
Journal article; Peer reviewed
Background
We aimed to assess whether high-dose preoperative chemoradiotherapy (CRT) improves outcome in esophageal cancer patients compared to surgery alone and to define possible prognostic factors for overall survival.
Methods
Hundred-and-seven patients with disease stage IIA - III were treated with either surgery alone (n = 45) or high-dose preoperative CRT (n = 62). The data were collected retrospectively. Sixty-seven patients had adenocarcinomas, 39 squamous cell carcinomas and one undifferentiated carcinoma. CRT was given as three intensive chemotherapy courses by cisplatin 100 mg/m2 on day 1 and 5-fluorouracil 1000 mg/m2/day, from day 1 through day 5 as continuous infusion. One course was given every 21 days. The last two courses were given concurrent with high-dose radiotherapy, 2 Gy/fraction and a median dose of 66 Gy. Kaplan-Meier survival analysis with log rank test was used to obtain survival data and Cox Regression multivariate analysis was used to define prognostic factors for overall survival.
Results
Toxicity grade 3 of CRT occurred in 30 (48.4%) patients and grade 4 in 24 (38.7%) patients of 62 patients. One patient died of neutropenic infection (grade 5). Fifty percent (31 patients) in the CRT group did undergo the planned surgery. Postoperative mortality rate was 9% and 10% in the surgery alone and CRT+ surgery groups, respectively (p = 1.0). Median overall survival was 11.1 and 31.4 months in the surgery alone and CRT+ surgery groups, respectively (log rank test, p = 0.042). In the surgery alone group one, 3 and 5 year survival rates were 44%, 24% and 16%, respectively and in the CRT+ surgery group they were 68%, 44% and 29%, respectively. By multivariate analysis we found that age of patient, performance status, alcoholism and > = 4 pathological positive lymph nodes in resected specimen were significantly associated with overall survival, whereas high-dose preoperative CRT was not.
Conclusion
We found no significant survival advantage in esophageal cancer stage IIA-III following preoperative high-dose CRT compared to surgery alone. Patient's age, performance status, alcohol abuse and number of positive lymph nodes were prognostic factors for overall survival
Tue, 01 Jun 2010 00:00:00 GMThttp://hdl.handle.net/1956/46862010-06-01T00:00:00ZCapillary leakage in post-cardiac arrest survivors during therapeutic hypothermia - a prospective, randomised studyhttp://hdl.handle.net/1956/4682
Capillary leakage in post-cardiac arrest survivors during therapeutic hypothermia - a prospective, randomised study
Heradstveit, Bård E.; Guttormsen, Anne Berit; Langørgen, Jørund; Hammersborg, Stig-Morten; Wentzel-Larsen, Tore; Fanebust, Rune; Larsson, Elna-Marie; Heltne, Jon-Kenneth
Journal article
<p>Background:
Fluids are often given liberally after the return of spontaneous circulation. However, the optimal fluid regimen in survivors of cardiac arrest is unknown. Recent studies indicate an increased fluid requirement in post-cardiac arrest patients. During hypothermia, animal studies report extravasation in several organs, including the brain. We investigated two fluid strategies to determine whether the choice of fluid would influence fluid requirements, capillary leakage and oedema formation.</p>
<p>Methods:
19 survivors with witnessed cardiac arrest of primary cardiac origin were allocated to either 7.2% hypertonic saline with 6% poly (O-2-hydroxyethyl) starch solution (HH) or standard fluid therapy (Ringer's Acetate and saline 9 mg/ml) (control). The patients were treated with the randomised fluid immediately after admission and continued for 24 hours of therapeutic hypothermia.</p>
<p>Results:
During the first 24 hours, the HH patients required significantly less i.v. fluid than the control patients (4750 ml versus 8010 ml, p = 0.019) with comparable use of vasopressors. Systemic vascular resistance was significantly reduced from 0 to 24 hours (p = 0.014), with no difference between the groups. Colloid osmotic pressure (COP) in serum and interstitial fluid (p &lt; 0.001 and p = 0.014 respectively) decreased as a function of time in both groups, with a more pronounced reduction in interstitial COP in the crystalloid group. Magnetic resonance imaging of the brain did not reveal vasogenic oedema.</p>
<p>Conclusions:
Post-cardiac arrest patients have high fluid requirements during therapeutic hypothermia, probably due to increased extravasation. The use of HH reduced the fluid requirement significantly. However, the lack of brain oedema in both groups suggests no superior fluid regimen. Cardiac index was significantly improved in the group treated with crystalloids. Although we do not associate HH with the renal failures that developed, caution should be taken when using hypertonic starch solutions in these patients.</p>
Tue, 25 May 2010 00:00:00 GMThttp://hdl.handle.net/1956/46822010-05-25T00:00:00ZPre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical servicehttp://hdl.handle.net/1956/4676
Pre-hospital intubation by anaesthesiologists in patients with severe trauma: an audit of a Norwegian helicopter emergency medical service
Sollid, Stephen J. M.; Lossius, Hans Morten; Søreide, Eldar
Journal article; Peer reviewed
Background
Anaesthesiologists are airway management experts, which is one of the reasons why they serve as pre-hospital emergency physicians in many countries. However, limited data are available on the actual quality and safety of anaesthesiologist-managed pre-hospital endotracheal intubation (ETI). To explore whether the general indications for ETI are followed and what complications are recorded, we analysed the use of pre-hospital ETI in severely traumatised patients treated by anaesthesiologists in a Norwegian helicopter emergency medical service (HEMS).
Methods
A retrospective audit of prospectively registered data concerning patients with trauma as the primary diagnosis and a National Committee on Aeronautics score of 4 - 7 during the period of 1994-2005 from a mixed rural/urban Norwegian HEMS was performed.
Results
Among the 1255 cases identified, 238 successful pre-hospital ETIs out of 240 attempts were recorded (99.2% success rate). Furthermore, we identified 47 patients for whom ETI was performed immediately upon arrival to the emergency department (ED). This group represented 16% of all intubated patients. Of the ETIs performed in the ED, 43 patients had an initial Glasgow Coma Score (GCS) < 9. Compared to patients who underwent ETI in the ED, patients who underwent pre-hospital ETI had significantly lower median GCS (3 (3-6) vs. 6 (4-8)), lower revised trauma scores (RTS) (3.8 (1.8-5.9) vs. 5.0 (4.1-6.0)), longer mean scene times (23 ± 13 vs. 11 ± 11 min) and longer mean transport times (22 ± 16 vs. 13 ± 14 min). The audit also revealed that very few airway management complications had been recorded.
Conclusions
We found a very high success rate of pre-hospital ETI and few recorded complications in the studied anaesthesiologist-manned HEMS. However, a substantial number of trauma patients were intubated first on arrival in the ED. This delay may represent a quality problem. Therefore, we believe that more studies are needed to clarify the reasons for and possible clinical consequences of the delayed ETIs.
Mon, 14 Jun 2010 00:00:00 GMThttp://hdl.handle.net/1956/46762010-06-14T00:00:00ZArachnoid cysts do not contain cerebrospinal fluid: A comparative chemical analysis of arachnoid cyst fluid and cerebrospinal fluid in adultshttp://hdl.handle.net/1956/4674
Arachnoid cysts do not contain cerebrospinal fluid: A comparative chemical analysis of arachnoid cyst fluid and cerebrospinal fluid in adults
Berle, Magnus; Wester, Knut; Ulvik, Rune Johan; Kroksveen, Ann Cathrine; Haaland, Øystein; Amiry-Moghaddam, Mahmood; Berven, Frode S.
Journal article; Peer reviewed
Background
Arachnoid cyst (AC) fluid has not previously been compared with cerebrospinal fluid (CSF) from the same patient. ACs are commonly referred to as containing "CSF-like fluid". The objective of this study was to characterize AC fluid by clinical chemistry and to compare AC fluid to CSF drawn from the same patient. Such comparative analysis can shed further light on the mechanisms for filling and sustaining of ACs.
Methods
Cyst fluid from 15 adult patients with unilateral temporal AC (9 female, 6 male, age 22-77y) was compared with CSF from the same patients by clinical chemical analysis.
Results
AC fluid and CSF had the same osmolarity. There were no significant differences in the concentrations of sodium, potassium, chloride, calcium, magnesium or glucose. We found significant elevated concentration of phosphate in AC fluid (0.39 versus 0.35 mmol/L in CSF; p = 0.02), and significantly reduced concentrations of total protein (0.30 versus 0.41 g/L; p = 0.004), of ferritin (7.8 versus 25.5 ug/L; p = 0.001) and of lactate dehydrogenase (17.9 versus 35.6 U/L; p = 0.002) in AC fluid relative to CSF.
Conclusions
AC fluid is not identical to CSF. The differential composition of AC fluid relative to CSF supports secretion or active transport as the mechanism underlying cyst filling. Oncotic pressure gradients or slit-valves as mechanisms for generating fluid in temporal ACs are not supported by these results.
Thu, 10 Jun 2010 00:00:00 GMThttp://hdl.handle.net/1956/46742010-06-10T00:00:00ZAssociations between tamoxifen, estrogens, and FSH serum levels during steady state tamoxifen treatment of postmenopausal women with breast cancerhttp://hdl.handle.net/1956/4673
Associations between tamoxifen, estrogens, and FSH serum levels during steady state tamoxifen treatment of postmenopausal women with breast cancer
Gjerde, Jennifer; Geisler, Jürgen; Lundgren, Steinar; Ekse, Dagfinn; Varhaug, Jan Erik; Mellgren, Gunnar; Steen, Vidar Martin; Lien, Ernst Asbjørn
Peer reviewed; Journal article
Background
The cytochrome P450 (CYP) enzymes 2C19, 2D6, and 3A5 are responsible for converting the selective estrogen receptor modulator (SERM), tamoxifen to its active metabolites 4-hydroxy-tamoxifen (4OHtam) and 4-hydroxy-N-demethyltamoxifen (4OHNDtam, endoxifen). Inter-individual variations of the activity of these enzymes due to polymorphisms may be predictors of outcome of breast cancer patients during tamoxifen treatment. Since tamoxifen and estrogens are both partly metabolized by these enzymes we hypothesize that a correlation between serum tamoxifen and estrogen levels exists, which in turn may interact with tamoxifen on treatment outcome. Here we examined relationships between the serum levels of tamoxifen, estrogens, follicle-stimulating hormone (FSH), and also determined the genotypes of CYP2C19, 2D6, 3A5, and SULT1A1 in 90 postmenopausal breast cancer patients.
Methods
Tamoxifen and its metabolites were measured by liquid chromatography-tandem mass spectrometry. Estrogen and FSH levels were determined using a sensitive radio- and chemiluminescent immunoassay, respectively.
Results
We observed significant correlations between the serum concentrations of tamoxifen, N-dedimethyltamoxifen, and tamoxifen-N-oxide and estrogens (p < 0.05). The genotype predicted CYP2C19 activity influenced the levels of both tamoxifen metabolites and E1.
Conclusions
We have shown an association between tamoxifen and its metabolites and estrogen serum levels. An impact of CYP2C19 predicted activity on tamoxifen, as well as estrogen kinetics may partly explain the observed association between tamoxifen and its metabolites and estrogen serum levels. Since the role of estrogen levels during tamoxifen therapy is still a matter of debate further prospective studies to examine the effect of tamoxifen and estrogen kinetics on treatment outcome are warranted.
Mon, 21 Jun 2010 00:00:00 GMThttp://hdl.handle.net/1956/46732010-06-21T00:00:00ZA concept for major incident triage: full-scaled simulation feasibility studyhttp://hdl.handle.net/1956/4665
A concept for major incident triage: full-scaled simulation feasibility study
Rehn, Marius; Andersen, Jan E.; Vigerust, Trond; Krüger, Andreas J.; Lossius, Hans Morten
Journal article; Peer reviewed
Background
Efficient management of major incidents involves triage, treatment and transport. In the absence of a standardised interdisciplinary major incident management approach, the Norwegian Air Ambulance Foundation developed Interdisciplinary Emergency Service Cooperation Course (TAS). The TAS-program was established in 1998 and by 2009, approximately 15 500 emergency service professionals have participated in one of more than 500 no-cost courses. The TAS-triage concept is based on the established triage Sieve and Paediatric Triage Tape models but modified with slap-wrap reflective triage tags and paediatric triage stretchers. We evaluated the feasibility and accuracy of the TAS-triage concept in full-scale simulated major incidents.
Methods
The learners participated in two standardised bus crash simulations: without and with competence of TAS-triage and access to TAS-triage equipment. The instructors calculated triage accuracy and measured time consumption while the learners participated in a self-reported before-after study. Each question was scored on a 7-point Likert scale with points labelled "Did not work" (1) through "Worked excellent" (7).
Results
Among the 93 (85%) participating emergency service professionals, 48% confirmed the existence of a major incident triage system in their service, whereas 27% had access to triage tags. The simulations without TAS-triage resulted in a mean over- and undertriage of 12%. When TAS-Triage was used, no mistriage was found. The average time from "scene secured to all patients triaged" was 22 minutes (range 15-32) without TAS-triage vs. 10 minutes (range 5-21) with TAS-triage. The participants replied to "How did interdisciplinary cooperation of triage work?" with mean 4,9 (95% CI 4,7-5,2) before the course vs. mean 5,8 (95% CI 5,6-6,0) after the course, p < 0,001.
Conclusions
Our modified triage Sieve tool is feasible, time-efficient and accurate in allocating priority during simulated bus accidents and may serve as a candidate for a future national standard for major incident triage.
Wed, 11 Aug 2010 00:00:00 GMThttp://hdl.handle.net/1956/46652010-08-11T00:00:00ZVariations in the length of stay of intensive care unit nonsurvivors in three scandinavian countrieshttp://hdl.handle.net/1956/4648
Variations in the length of stay of intensive care unit nonsurvivors in three scandinavian countries
Strand, Kristian; Walther, Sten M.; Reinikainen, Matti; Ala-Kokko, Tero; Nolin, Thomas; Martner, Jan; Mussalo, Petteri; Søreide, Eldar; Flaatten, Hans
Journal article
<p>Introduction:
The length of stay (LOS) in intensive care unit (ICU) nonsurvivors is not often reported, but represents an important indicator of the use of resources. LOS in ICU nonsurvivors may also be a marker of cultural and organizational differences between units. In this study based on the national intensive care registries in Finland, Sweden, and Norway, we aimed to report intensive care mortality and to document resource use as measured by LOS in ICU nonsurvivors.</p>
<p>Methods:
Registry data from 53,305 ICU patients in 2006 were merged into a single database. ICU nonsurvivors were analyzed with regard to LOS within subgroups by univariate and multivariate analysis (Cox proportional hazards regression).</p>
<p>Results:
Vital status at ICU discharge was available for 52,255 patients. Overall ICU mortality was 9.1%. Median LOS of the nonsurvivors was 1.3 days in Finland and Sweden, and 1.9 days in Norway. The shortest LOS of the nonsurvivors was found in patients older than 80 years, emergency medical admissions, and the patients with the highest severity of illness. Multivariate analysis confirmed the longer LOS in Norway when corrected for age group, admission category, sex, and type of hospital. LOS in nonsurvivors was found to be inversely related to the severity of illness, as measured by APACHE II and SAPS II.</p>
<p>Conclusions:
Despite cultural, religious, and educational similarities, significant variations occur in the LOS of ICU nonsurvivors among Finland, Norway, and Sweden. Overall, ICU mortality is low in the Scandinavian countries.</p>
Mon, 04 Oct 2010 00:00:00 GMThttp://hdl.handle.net/1956/46482010-10-04T00:00:00ZSteppingstones to the implementation of an inhospital fracture and dislocation registry using the AO/OTA classification: compliance, completeness and commitmenthttp://hdl.handle.net/1956/4642
Steppingstones to the implementation of an inhospital fracture and dislocation registry using the AO/OTA classification: compliance, completeness and commitment
Meling, Terje; Harboe, Knut; Arthursson, Astvaldur J.; Søreide, Kjetil
Peer reviewed; Journal article
Background
Musculoskeletal trauma represents a considerable global health burden, however reliable population-based incidence data are scarce. A fracture and dislocation registry was established within a well-defined population. An audit of the establishment process, feasibility of the registry work and report of the collected data is given.
Methods
Demographic data, fracture type and location, mode of treatment, and the reasons for the secondary procedures were collected and scored using recognized systems, such as the AO/OTA classification and the Gustilo-Anderson classification for open fractures. The reporting was done in the operation planning program by the involved orthopaedic surgeon. Both inpatient and day-case procedures were collected. Data were collected prospectively from 2006 until 2010. Compliance among the surgeons and completeness and accuracy of the data was continuously assured by an orthopaedic surgeon.
Results
During the study period, 39 orthopaedic surgeons were involved in the recording of a total of 8,188 procedures, consisting of primary treatment of 4,986 long bone fractures, 467 non long bone fractures, 123 dislocations and 2,612 secondary treatments. In the study period 532 fractures or dislocations were treated at least once for one or more serious complications. For the index year of 2009, a total of 5710 fractures or dislocations were treated in the emergency department or hospitalized, of which the 1594 (28%) were treated at the inpatient or day-case operation rooms, thus registered in the FDR. Quality assurance, educational incentives and continuous feedback between coders and controller in the integrated electronic system are available and used through the features of the electronic database.
Conclusions
Implementing an integrated registry of fractures and dislocations with the electronic hospital system has been possible despite several users involved. The electronic system and the data controller provide for completeness and validity. The FDR has become an indispensable tool for the department for planning and education and will serve as a prerequisite for the conduct and execution of future prospective trials within the department. Further, other departments with similar electronic patient files may fairly easily adopt this system for implementation.
Mon, 18 Oct 2010 00:00:00 GMThttp://hdl.handle.net/1956/46422010-10-18T00:00:00ZPatient-reported outcomes as predictors of 10-year survival in women after acute myocardial infarctionhttp://hdl.handle.net/1956/4638
Patient-reported outcomes as predictors of 10-year survival in women after acute myocardial infarction
Norekvål, Tone M.; Fridlund, Bengt; Rokne, Berit; Segadal, Leidulf; Wentzel-Larsen, Tore; Nordrehaug, Jan Erik
Peer reviewed; Journal article
Background
Patient-reported outcomes are increasingly seen as complementary to biomedical measures. However, their prognostic importance has yet to be established, particularly in female long-term myocardial infarction (MI) survivors. We aimed to determine whether 10-year survival in older women after MI relates to patient-reported outcomes, and to compare their survival with that of the general female population.
Methods
We included all women aged 60-80 years suffering MI during 1992-1997, and treated at one university hospital in Norway. In 1998, 145 (60% of those alive) completed a questionnaire package including socio-demographics, the Sense of Coherence Scale (SOC-29), the World Health Organization Quality of Life Instrument Abbreviated (WHOQOL-BREF) and an item on positive effects of illness. Clinical information was based on self-reports and hospital medical records data. We obtained complete data on vital status.
Results
The all-cause mortality rate during the 1998-2008 follow-up of all patients was 41%. In adjusted analysis, the conventional predictors s-creatinine (HR 1.26 per 10% increase) and left ventricular ejection fraction below 30% (HR 27.38), as well as patient-reported outcomes like living alone (HR 6.24), dissatisfaction with self-rated health (HR 6.26), impaired psychological quality of life (HR 0.60 per 10 points difference), and experience of positive effects of illness (HR 6.30), predicted all-cause death. Major adverse cardiac and cerebral events were also significantly associated with both conventional predictors and patient-reported outcomes. Sense of coherence did not predict adverse events. Finally, 10-year survival was not significantly different from that of the general female population.
Conclusion
Patient-reported outcomes have long-term prognostic importance, and should be taken into account when planning aftercare of low-risk older female MI patients.
Thu, 25 Nov 2010 00:00:00 GMThttp://hdl.handle.net/1956/46382010-11-25T00:00:00ZType 1 plasminogen activator inhibitor (PAI-1) in clear cell renal cell carcinoma (CCRCC) and its impact on angiogenesis, progression and patient survival after radical nephrectomyhttp://hdl.handle.net/1956/4635
Type 1 plasminogen activator inhibitor (PAI-1) in clear cell renal cell carcinoma (CCRCC) and its impact on angiogenesis, progression and patient survival after radical nephrectomy
Zubac, Dragomir; Wentzel-Larsen, Tore; Seidal, Tomas; Bostad, Leif
Journal article; Peer reviewed
Background
To examine the expression of type 1 plasminogen inhibitor (PAI-1) in clear cell renal cell carcinoma (CCRCC), and its possible association with microvessel density (MVD), the expression of thrombospondin-1 (TSP-1), nuclear grade, tumour stage, continuously coded tumour size (CCTS) and to assess the value of PAI as a prognostic marker in 162 patients with CCRCC treated with radical nephrectomy.
Methods
A total of 172 consecutive patients with CCRCC treated with radical nephrectomy were enrolled in the study. The expression of PAI-1, TSP-1 and factor VIII were analysed on formalin-fixed, paraffin-embedded tissues without knowledge of the clinical outcome. Ten cases, where PAI-1 immunohistochemistry was not possible due to technical problems and lack of material, were excluded. Sixty-nine patients (43%) died of RCC, while 47 patients (29%) died of other diseases. Median follow-up was 13.8 years for the surviving 46 patients (28%).
Results
Nine percent of the tumours showed PAI-1 positivity. High expression of PAI-1 was significantly inversely correlated with TSP-1 (p = 0.046) and directly with advanced stage (p = 0.008), high NG (3+4) (p = 0.002), tumour size (p = 0.011), microvessel density (p = 0.049) and disease progression (p = 0.002). In univariate analysis PAI-1 was a significant prognosticator of cancer-specific survival (CSS) (p < 0.001). Multivariate analysis revealed that TNM stage (p < 0.001), PAI-1 (p = 0.020), TSP-1 (p < 0.001) and MVD (p = 0.007) were independent predictors of CSS.
Conclusions
PAI-1 was found to be an independently significant prognosticator of CSS and a promoter of tumour angiogenesis, aggressiveness and progression in CCRCC.
Fri, 03 Dec 2010 00:00:00 GMThttp://hdl.handle.net/1956/46352010-12-03T00:00:00ZChecklists in the operating room: Help or hurdle? A qualitative study on health workers' experienceshttp://hdl.handle.net/1956/4628
Checklists in the operating room: Help or hurdle? A qualitative study on health workers' experiences
Thomassen, Øyvind; Brattebø, Guttorm; Heltne, Jon-Kenneth; Søfteland, Eirik; Espeland, Ansgar
Journal article
<p>Background:
Checklists have been used extensively as a cognitive aid in aviation; now, they are being introduced in many areas of medicine. Although few would dispute the positive effects of checklists, little is known about the process of introducing this tool into the health care environment. In 2008, a pre-induction checklist was implemented in our anaesthetic department; in this study, we explored the nurses' and physicians' acceptance and experiences with this checklist.</p>
<p>Method:
Focus group interviews were conducted with a purposeful sample of checklist users (nurses and physicians) from the Department of Anaesthesia and Intensive Care in a tertiary teaching hospital. The interviews were analysed qualitatively using systematic text condensation.</p>
<p>Results:
Users reported that checklist use could divert attention away from the patient and that it influenced workflow and doctor-nurse cooperation. They described senior consultants as both sceptical and supportive; a head physician with a positive attitude was considered crucial for successful implementation. The checklist improved confidence in unfamiliar contexts and was used in some situations for which it was not intended. It also revealed insufficient equipment standardisation.</p>
<p>Conclusion:
Our findings suggest several issues and actions that may be important to consider during checklist use and implementation.</p>
Mon, 20 Dec 2010 00:00:00 GMThttp://hdl.handle.net/1956/46282010-12-20T00:00:00ZPrognostic models for the early care of trauma patients: a systematic reviewhttp://hdl.handle.net/1956/4626
Prognostic models for the early care of trauma patients: a systematic review
Rehn, Marius; Perel, Pablo; Blackhall, Karen; Lossius, Hans Morten
Journal article
Background: Early identification of major trauma may contribute to timely emergency care and rapid transport to
an appropriate health-care facility. Several prognostic trauma models have been developed to improve early
clinical decision-making.
Methods: We systematically reviewed models for the early care of trauma patients that included 2 or more
predictors obtained from the evaluation of an adult trauma victim, investigated their quality and described their
characteristics.
Results: We screened 4 939 records for eligibility and included 5 studies that derivate 5 prognostic models and 9
studies that validate one or more of these models in external populations. All prognostic models intended to
change clinical practice, but none were tested in a randomised clinical trial. The variables and outcomes were valid,
but only one model was derived in a low-income population. Systolic blood pressure and level of consciousness
were applied as predictors in all models.
Conclusions: The general impression is that the models perform well in predicting survival. However, there are
many areas for improvement, including model development, handling of missing data, analysis of continuous
measures, impact and practicality analysis.
Sun, 20 Mar 2011 00:00:00 GMThttp://hdl.handle.net/1956/46262011-03-20T00:00:00ZChoice of psychological coping in laryngectomized, head and neck squamous cell carcinoma patients versus multiple sclerosis patientshttp://hdl.handle.net/1956/4566
Choice of psychological coping in laryngectomized, head and neck squamous cell carcinoma patients versus multiple sclerosis patients
Aarstad, Anne Kari Hersvik; Lode, Kirsten; Larsen, Jan Petter; Bru, Edvin; Aarstad, Hans Jørgen
Peer reviewed; Journal article
To be treated for cancer must be a frightening experience. Yet quality of life (QoL) of successfully treated cancer patients seems to be relatively similar in comparison with QoL of a general population, with psychological coping partly responsible for this finding. When measuring choice of coping, the nature of coping score levels constituting appropriate scores, and whether score levels rely on the context of the disease has not been settled. We have studied the COPE coping responses as related to disease in successfully treated head and neck squamous cell carcinoma (HNSCC) patient groups (general and laryngectomized), as well as compared to multiple sclerosis (MS) patients. The COPE response patterns have also been compared to the Beck depression inventory (BDI) scores. Age and gender of patients were not directly associated with choice of coping. Within the problem-focused coping indexes, the coping index “active coping” was reported to be most utilized among HNSCC patients, whereas “coping by suppression” and “coping by social support” were most utilized among MS patients. Emotional-focused coping was most prevalent among HNSCC patients and lowest among the MS patients. Level of avoidance coping was similar between the groups. The coping of the general HNSCC patients differed most from the MS patients. An association was shown between increased coping efforts and lowered mood. In particular, avoidance coping was associated with lowered mood. These associations were stronger among the MS patients than HNSCC patients. Drinking to cope was most prevalent among the laryngectomized group, and was correlated with BDI scores in all groups. Furthermore, adequate coping seems to be to limit avoidance coping and promote coping by acceptance. The response pattern of the COPE inventory seems to be valid among HNSCC and MS patients.
Thu, 18 Nov 2010 00:00:00 GMThttp://hdl.handle.net/1956/45662010-11-18T00:00:00ZA pan-European survey of research in end-of-life cancer carehttp://hdl.handle.net/1956/4555
A pan-European survey of research in end-of-life cancer care
Sigurdardottir, Katrin Ruth; Haugen, Dagny Faksvåg; Bausewein, Claudia; Higginson, Irene J.; Harding, Richard; Rosland, Jan Henrik; Kaasa, Stein
Peer reviewed; Journal article
Background To date, there is no coordinated strategy for
end-of-life (EOL) cancer care research in Europe. The
PRISMA (Reflecting the Positive Diversities of European
Priorities for Research and Measurement in End-of-life
Care) project is aiming to develop a programme integrating
research and measurement in EOL care. This survey aimed
to map and describe present EOL cancer care research in
Europe and to identify priorities and barriers.
Material and methods A questionnaire of 62 questions was
developed and 201 researchers in 41 European countries
were invited to complete it online in May 2009. An open
invitation to participate was posted on the internet.
Results Invited contacts in 36 countries sent 127 replies;
eight additional responses came through websites. A total
of 127 responses were eligible for analysis. Respondents
were 69 male and 58 female, mean age 49 (28–74) years;
85% of the scientific team leaders were physicians.
Seventy-one of 127 research groups were located in a
teaching hospital or cancer centre. Forty-five percent of the
groups had only one to five members and 28% six to ten
members. Sixty-three of 92 groups reported specific
funding for EOL care research. Seventy-five percent of
the groups had published papers in journals with impact
factor ≤5 in the last 3 years; 8% had published in journals
with impact factor >10. Forty-four out of 90 groups
reported at least one completed Ph.D. in the last 3 years.
The most frequently reported active research areas were
pain, assessment and measurement tools, and last days of
life and quality of death. Very similar areas—last days of
life and quality of death, pain, fatigue and cachexia, and
assessment and measurement tools—were ranked as the
most important research priorities. The most important
research barriers were lack of funding, lack of time, and
insufficient knowledge/expertise.
Conclusions Most research groups in EOL care are small.
The few large groups (14%) had almost half of the reported
publications, and more than half of the current Ph.D.
Tue, 30 Nov 2010 00:00:00 GMThttp://hdl.handle.net/1956/45552010-11-30T00:00:00ZTemporary Prosthetic Shunt to Permanent Aortic Prosthesis in a Patient with an Infected Thoracoabdominal Aneurysm to Shorten Ischemia Timehttp://hdl.handle.net/1956/4495
Temporary Prosthetic Shunt to Permanent Aortic Prosthesis in a Patient with an Infected Thoracoabdominal Aneurysm to Shorten Ischemia Time
Dregelid, Einar; Algaard, Axel
Peer reviewed; Journal article
High operative mortality of infected thoracoabdominal aortic aneurysms (ITAA) is partly attributable to
ischemic injury during aortic clamping. We report a 62-year-old man with biliary cirrhosis, who developed a rapidly
enlarging ITAA secondary to thoracolumbar osteomyelitis. Additional infectious foci were found in the pubic and ischial
bones and in the left lung. Blood cultures gave growth of streptococcus pneumoniae. The aneurysm was repaired through
a thoracoabdominal incision with a Dacron prosthesis. Prior to aneurysm repair, a prosthetic shunt was anastomosed end –
to- side to the aortic prosthesis and to the descending aorta using a side-biting clamp. The shunt allowed perfusion of the
lower body and of renal and visceral vessels after 45 minutes, the time needed to resect infected tissue and complete the
distal anastomosis. The proximal anastomosis and orthopedic treatment of the spinal osteomyelitis could be performed,
while the lower body and visceral organs were perfused.
Postoperatively, the patient developed hypotension and increasing lactacidosis. Laparotomy revealed intestinal infarction,
and gut resection was performed. Following a temporary improvement, he developed multiorgan failure and candida
sepsis and died after 32 days. No atheroemboli were found in arteries of resected intestines. Portal hypertension most
likely was present and it could be calculated that minimum intestinal perfusion pressure the night after the operation could
have been in the range of 30-37 mm Hg, which probably was not enough to maintain aerobic metabolism. In the presence
of aortic atheromas it may be advisable to divert blood to the shunt from an axillary artery.
Fri, 01 Jan 2010 00:00:00 GMThttp://hdl.handle.net/1956/44952010-01-01T00:00:00ZMorbidity and Mortality after Emergency and Urgent Colorectal Surgery for Malignant and Benign Diseasehttp://hdl.handle.net/1956/4494
Morbidity and Mortality after Emergency and Urgent Colorectal Surgery for Malignant and Benign Disease
Ellensen, Vegard Skalstad; Elshove-Bolk, Jolande; Baatrup, Gunnar
Peer reviewed; Journal article
Abstract: Aim: The aim of this study was to determine short and long-term morbidity and mortality rates after emergency
colorectal surgery for benign and malignant disease in a high volume tertiary referral hospital in order to define factors
predictive for outcome.
Material and Methods: Characteristics and outcome of 196 consecutive emergency and 292 consecutive elective colorectal
procedures were studied. A total of 91/196 emergency procedures were performed for malignant disease. The procedures
reviewed included both palliative and curative procedures performed on an unselected patient population. Results
were analysed by Cox regression and Kaplan-Meier analysis.
Results: The total 30-day mortality for emergency and elective surgery was 20% and 3 % respectively, 36-month mortality
was 48% and 27%. The frequency of major or moderate complications after emergency procedures was 39%.
The strongest predictors for 30 day mortality after emergency surgery were ASA score (Odds Ratio 2.5) and age (OR 1.5).
Predictors for early postoperative complications were faecal contamination during surgery (OR 4.2) and ASA score (OR
2.0). The strongest predictor for 3 year mortality after emergency surgery was malignant disease (OR = 5.0). Other predictors
for long-term outcome were procedures performed and degree of specialization of the surgeon.
Conclusions: Short-term outcome is associated with patient and disease related factors, whereas long-term outcome is
also correlated to the primary diseases, procedures performed and the degree of specialization of the surgeon. Decisions
concerning the level of qualifications required for emergency procedures should be based upon patient and disease related
factors as well as the procedure to be performed.
Thu, 01 Jan 2009 00:00:00 GMThttp://hdl.handle.net/1956/44942009-01-01T00:00:00ZThe prognostic relevance of interactions between venous invasion, lymph node involvement and distant metastases in renal cell carcinoma after radical nephrectomyhttp://hdl.handle.net/1956/4439
The prognostic relevance of interactions between venous invasion, lymph node involvement and distant metastases in renal cell carcinoma after radical nephrectomy
Zubac, Dragomir; Bostad, Leif; Seidal, Tomas; Wentzel-Larsen, Tore; Haukaas, Svein Andreas
Journal article; Peer reviewed
Background: To investigate a possible prognostic significance of interactions between lymph node
invasion (LNI), synchronous distant metastases (SDM), and venous invasion (VI) adjusted for mode
of detection, Eastern Cooperative Oncology Group performance status (ECOG PS), erythrocyte
sedimentation rate (ESR) and tumour size (TS) in 196 patients with renal cell carcinoma treated
with radical nephrectomy.
Methods: Median follow-up was 5.5 years (mean 6.9 years; range 0.01–19.4). The mode of
detection, ECOG PS, ESR and TS were obtained from the patients' records. Vena cava invasion and
distant metastases were detected by preoperative imaging. The surgical specimens were examined
for pathological stage, LNI and VI.
Results: The univariate analyses showed significant impact of VI, LNI, SDM, ESR and TS (p < 0.001),
as well as mode of detection (p = 0.003) and ECOG PS (p = 0.002) on cancer specific survival. In
multivariate analyses LNI was significantly associated with survival only in patients without SDM or
VI (p < 0.001) with a hazard ratio of 9.0. LNI lost its prognostic significance when SDM or VI was
present.
Conclusion: Our findings underline the prognostic importance of the status of the lymph nodes.
LNI, SDM, ESR, and VI were independently associated with cancer specific survival after radical
nephrectomy. LNI provided the strongest prognostic information for patients without SDM or VI
whereas SDM and VI had strongest impact on survival when there was no nodal involvement.
Fri, 19 Dec 2008 00:00:00 GMThttp://hdl.handle.net/1956/44392008-12-19T00:00:00ZPrognostic factors in renal cell carcinoma. A retrospective population based study focusing on the clear cell typehttp://hdl.handle.net/1956/4438
Prognostic factors in renal cell carcinoma. A retrospective population based study focusing on the clear cell type
Zubac, Dragomir
Doctoral thesis
Fri, 24 Sep 2010 00:00:00 GMThttp://hdl.handle.net/1956/44382010-09-24T00:00:00ZRisk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approachhttp://hdl.handle.net/1956/4369
Risk assessment of pre-hospital trauma airway management by anaesthesiologists using the predictive Bayesian approach
Sollid, Stephen J. M.; Lossius, Hans Morten; Nakstad, Anders R.; Aven, Terje; Søreide, Eldar
Peer reviewed; Journal article
Introduction:
Endotracheal intubation (ETI) has been considered an essential part of pre-hospital advanced life support. Pre-hospital ETI, however, is a complex intervention also for airway specialist like anaesthesiologists working as pre-hospital emergency physicians. We therefore wanted to investigate the quality of pre-hospital airway management by anaesthesiologists in severely traumatised patients and identify possible areas for improvement.
Method:
We performed a risk assessment according to the predictive Bayesian approach, in a typical anaesthesiologist-manned Norwegian helicopter emergency medical service (HEMS). The main focus of the risk assessment was the event where a patient arrives in the emergency department without ETI despite a pre-hospital indication for it.
Results:
In the risk assessment, we assigned a high probability (29%) for the event assessed, that a patient arrives without ETI despite a pre-hospital indication. However, several uncertainty factors in the risk assessment were identified related to data quality, indications for use of ETI, patient outcome and need for special training of ETI providers.
Conclusion:
Our risk assessment indicated a high probability for trauma patients with an indication for pre-hospital ETI not receiving it in the studied HEMS. The uncertainty factors identified in the assessment should be further investigated to better understand the problem assessed and consequences for the patients. Better quality of pre-hospital airway management data could contribute to a reduction of these uncertainties.
Wed, 21 Apr 2010 00:00:00 GMThttp://hdl.handle.net/1956/43692010-04-21T00:00:00ZClinical aspects in the late stage of whiplash injuryhttp://hdl.handle.net/1956/3695
Clinical aspects in the late stage of whiplash injury
Kaale, Bertel Rune
Doctoral thesis
Fri, 13 Nov 2009 00:00:00 GMThttp://hdl.handle.net/1956/36952009-11-13T00:00:00ZThe use of prosthetic grafts in above-knee femoropopliteal bypass surgery : a clinical study of long-term results and risk factors for failurehttp://hdl.handle.net/1956/2328
The use of prosthetic grafts in above-knee femoropopliteal bypass surgery : a clinical study of long-term results and risk factors for failure
Pedersen, Gustav
Doctoral thesis
Purpose:
The purpose of this study has been to investigate the results of above-knee
prosthetic femoropopliteal bypass surgery and to identify risk factors for
complications and graft failure. The influence of comorbidity, degree of chronic leg
ischaemia, preoperative angiographic run-off score and intraoperative flow
measurements on long-term results were investigated. Furthermore, local infections
and the outcome of treating occluded prosthetic grafts were studied.
Methods:
Two-hundred-and-thirty-seven patients (156 men, 81 women) were subjected
to 252 above-knee prosthetic femoropopliteal bypass operations at Haukeland
University Hospital between Jan 1990 and Dec 2001. One hundred and forty-one
graft implantations (129 patients) were done for intermittent claudication and 111
(108 patients) for critical ischaemia. Patient data were prospectively recorded in a
database registry. Some data were supplemented from patients records. Occlusion
dates, complications, re-operations including amputations, and mortality were also
recorded. Patient characteristics, anatomical risk factors and intraoperative flow
measurements were analysed for impact on results after surgery.
Survival, limb salvage and patency rates were analysed with the Product limit
method and illustrated as Kaplan-Meier curves. The risk factors were subjected to
univariate analysis using the log rank test for impact on survival, limb salvage and
patency rates. Variables approaching significance were included in multivariate
analysis performed with the Cox proportional hazard model. Results:
Paper I. Surgical site infection was recorded after 7.8 % of the operations and graft
infection after 12 %. The risk of developing a local infection was significantly
correlated with postoperative lymph fistula. Redo surgery was associated with graft
infection. Graft infections caused by Staph. Aur. always warranted surgery, either
local revision or graft excision.
Paper II. For grafts implanted for intermittent claudication, the assisted primary
patency rates were 62 % at 2 years and 44 % at 5 years. The 5-year patency rate for
smokers was 24 % versus 67 % for non-smokers (p < 0.01). A previous history of
cerebral infarction was significantly associated with reduced graft patency.
Preoperative s-creatinine > 125 mmol/L was significantly associated with reduced
survival.
Paper III. The 30-day mortality rate of patients operated for critical ischaemia was
5.5 %. The 2- and 5-year survival was 72 % and 42 %, whereas the limb salvage rates
at 2 and 5 years were 83 % and 73 %, respectively. The 2-year primary patency rate
for smokers was 38 % versus 62 % for non-smokers (p = 0.018, hazard ratio 2.18).
Smoking and tissue loss were significantly associated with reduced secondary
patency.
Paper IV. Basal flow measurements were not related to patency. The 2- and 5-year
patency rates for grafts with a papaverine flow < 500 ml/min were 48 % and 18 %
compared with 66 % and 52 % for grafts with a papaverine flow ≥ 500 ml/min (p =
0.012, hazard ratio 2.6). Two and 5-year patency rates for smokers vs non-smokers
were 44 % and 18 % vs 69 % and 54 %. Smoking (p = 0.008, hazard ratio 2.38) and
poor run-off score (p = 0.009, hazard ratio 2.38) were independent risk factors for
reduced patency. Poor run-off score did not correlate with low values of measured
basal or papaverine flow.
Paper V. Half the 24 initial procedures to restore patency of occluded grafts
originally implanted for critical ischaemia failed within a month. Outcome of second or third-time redo procedures were similar. Primary patency rates of all 55 redo
procedures were 32 % at three months, 28 % at six months and 12 % at 12 months.
The results of thrombectomy and thrombolysis were similar. Re-opened grafts
additionally treated for an underlying anastomotic stenosis had significantly better
patency, as compared with re-opened grafts without a pre-existing stenosis (p =
0.027, hazard ratio 2.813).
Conclusions:
The results regarding survival, limb salvage and patency are comparable to
previous reports. The results underline that a long observation period is necessary to
achieve full overview of complications and the impact of risk factors.
Infectious complications after prosthetic femoropopliteal bypass in the study
group were higher than previously reported. The results suggest that a selective
approach should be taken towards excision of infected femoropopliteal prostheses
according to the clinical presentation of the graft infection and the type of bacteriae
involved.
A conservative attitude is recommended towards placing a prosthetic graft in
the above-knee femoropopliteal position for intermittent claudication. The finding of
reduced patency rates in patients with a history of a cerebral insult operated for
intermittent claudication need further studies to be verified. Patients with intermittent
claudication and renal impairment reveal poor survival, indicating renal impairment
as a relative contraindication for surgical treatment. Smokers have inferior patency
rates when operated for intermittent claudication as well as for critical ischaemia.
Poor angiographic run-off score was also associated with inferior patency rates.
These findings indicate that prosthetic femoropopliteal bypass is not very suitable for
these groups of patients. Furthermore, the poor secondary patency rates of smokers as well as for patients with tissue loss suggest that these patients may benefit from
alternative treatment modalities to re-opening an occluded bypass.
A papaverine flow of < 500 ml/min is associated with reduced patency.
Additional antithrombotic medication and frequent follow-up may be considered for
these grafts. Redo procedures for occluded grafts originally implanted for critical
ischaemia are of limited value and cannot be recommended except in cases with a
proven graft-related stenosis. Other cases in need of re-intervention should be treated
with either a new arterial reconstruction or an amputation.
Based on the findings in this study, the following issues must be evaluated
when offering an above-knee prosthetic femoropopliteal bypass for chronic limb
ischaemia: patient comorbidity, smoking, degree of ischaemia and angiographic runoff
score. Careful selection of patients subjected to above-knee prosthetic bypass
surgery for chronic ischaemia is mandatory to achieve the optimal gain of the
operation.
Thu, 24 May 2007 00:00:00 GMThttp://hdl.handle.net/1956/23282007-05-24T00:00:00ZA 3-D post-mortem model provides rationale for complications in gastrointestinal surgery : a post-mortem corrosion-cast modelhttp://hdl.handle.net/1956/2320
A 3-D post-mortem model provides rationale for complications in gastrointestinal surgery : a post-mortem corrosion-cast model
Ignjatovic, Dejan
Doctoral thesis
Fri, 08 Jun 2007 00:00:00 GMThttp://hdl.handle.net/1956/23202007-06-08T00:00:00ZWear, fixation, and revision of hip prostheseshttp://hdl.handle.net/1956/2166
Wear, fixation, and revision of hip prostheses
Hallan, Geir
Doctoral thesis
Fri, 19 Jan 2007 00:00:00 GMThttp://hdl.handle.net/1956/21662007-01-19T00:00:00ZChild injuries in Bergen, Norway : identifying high-risk groups and activity specific injurieshttp://hdl.handle.net/1956/2075
Child injuries in Bergen, Norway : identifying high-risk groups and activity specific injuries
Brudvik, Christina
Doctoral thesis
Sammendrag (Norwegian summary)
Formålet med denne studien var å undersøke forekomsten av barneulykker i Bergen
sammenliknet med forekomsten andre steder innenlands og utenlands. Vi ønsket å undersøke
hvilke barn, karakterisert ved alder, kjønn eller andre faktorer, som oftest pådro seg ulike
skader. Det var også et mål å analysere hvilke skader som oftest oppsto under ulike typer
aktiviteter, og om nye aktiviteter medførte nye skadetyper. Det var en målsetting at
undersøkelsen ville gi velbegrunnete anbefalinger vedrørende forebygging av skader på barn.
Det var også av interesse å se på utfallet av vår behandling av en vanlig, men komplisert
skade, nemlig underarms- og håndleddsbrudd med feilstilling.
Hovedregistreringen har foregått ved Bergen Legevakt og Haukeland Universitetssykehus i
løpet av 1998 og danner grunnlaget for artikkel I, II, III og IV. I denne registreringen ble det
brukt elektroniske påminnere til legevaktens helsepersonell for å sikre at den ble mest mulig
komplett. Mer detaljerte og avgrensete registreringer av både gamle og nye aktiviteter har
foregått ved Bergen Legevakts røntgen- og såravdeling fra 2000 til 2002 og danner grunnlaget
for artikkel V og VI.
Det ble registrert rundt 7.000 nye skader på barn under 16 år, hvorav 1.725 var bruddskader.
Den totale årlige skadeinsidens var 9 per 100 barn under 6 år og 13 per 100 barn mellom 6 og
15 år. De yngste barna pådro seg oftest hodeskader mens de eldste fikk mest armskader. De
fleste skader var av mild eller moderat alvorlighetsgrad, men 4 barn døde. De alvorligste
skadene oppsto i trafikken. Hodeskade, inklusiv hjernerystelse, var den hyppigste
innleggelsesdiagnosen i sykehus. De fleste skader oppsto hjemme eller nær hjemmet.
Brannskader var hyppigst blant barn under 4 år og skyldtes oftest skolding fra varm drikke.
Jenter fra etniske minoriteter hadde en høy andel av de alvorligste brannskader i dette
registreringsåret. Skoleskader, inklusiv voldsskader, oppsto oftest i friminuttene og når barna
var uten voksent tilsyn. Blant aktiviteter hadde fotball den høyeste årlige skadeinsidens (11
per 1000 barn), fulgt av sykling (8 per 1000 barn). Den årlige insidensen av brudd blant barn i
Bergen kommune (245 per 10.000) var betydelig høyere enn tidligere påvist i andre norske
byer (Harstad, Stavanger, Drammen og Trondheim). Gutter i alderen 13-15 år hadde en
dobbelt så høy forekomst av brudd sammenliknet med jenter i samme alder. Mens 1/3 av
fotball- og sykkelskadene var brudd, utgjorde de hele 2/3 av rulleskøyte- og snøbrettskadene
og rammet oftest håndleddet. To spesielle bruddtyper forekom hyppigere i nye aktiviteter. Det
gjaldt bruddskader i håndrotens skafoidbein, som ellers forekommer svært sjelden hos barn og
unge, men som forekom i en høyere andel av bruddskadene ved bruk av rulleskøyter og
rullebrett enn i andre aktiviteter. En høy andel underarms- og håndleddsbrudd med volar
vinkling ble identifisert i forbindelse med bruk av sparkesykler. I begge tilfellene må det
vurderes om vanlig håndleddsbeskyttelse også kan forebygge disse bruddtypene. Sparkesykler
ble svært populære i 2000 og medførte mange skader dette første året, men skadeantallet
begynte å falle allerede året etter. Det var ellers interessant å merke seg at håndleddet også var
det vanligste bruddsted hos unge fotballspillere, og harde ballskudd var årsaken i hele 40% av
tilfellene. Dette gjør det logisk å skulle beskytte håndleddet så vel som skinneleggen under
denne aktiviteten.
Vi vurderte også funksjonen i håndledd og underarm til barn og unge som syv år tidligere
hadde hatt brudd med feilstillinger som måtte korrigeres. Våre behandlingsresultater var svært
gode, selv der det var en resterende feilstilling på 15 grader eller mer ved gipsfjerning.
Kontrollene indikerte en stor evne til remodellering av disse barnebruddene. Kun noen få med
høyere underarmsbrudd hadde redusert funksjon til tross for normale røntgenbilder.
Fri, 24 Nov 2006 00:00:00 GMThttp://hdl.handle.net/1956/20752006-11-24T00:00:00ZMultiple primary malignancies in patients with Renal Cell Carcinoma. - A national population-based cohort studyhttp://hdl.handle.net/1956/1132
Multiple primary malignancies in patients with Renal Cell Carcinoma. - A national population-based cohort study
Beisland, Christian; Talleraas, Olaug; Bakke, August; Norstein, Jarle
Pre-print from BJU Int, Beisland, C., Talleraas O., Bakke, A., Norstein J., Multiple primary malignancies in patients with Renal Cell Carcinoma. - A national population-based cohort study , Copyright 2006, Elsevier
Sun, 01 Jan 2006 00:00:00 GMThttp://hdl.handle.net/1956/11322006-01-01T00:00:00ZEpidemiological and clinical aspects in diagnosis and treatment of renal cell carcinomahttp://hdl.handle.net/1956/1131
Epidemiological and clinical aspects in diagnosis and treatment of renal cell carcinoma
Beisland, Christian
Doctoral thesis
Fri, 24 Feb 2006 00:00:00 GMThttp://hdl.handle.net/1956/11312006-02-24T00:00:00ZSelective Treatment of Symptomatic Gallstoneshttp://hdl.handle.net/1956/1101
Selective Treatment of Symptomatic Gallstones
Vetrhus, Morten
Doctoral thesis
List of papers
I. Vetrhus M, Søreide O, Solhaug JH, Nesvik I, Søndenaa K. Symptomatic, non-complicated
gallbladder stone disease. Operation or observation? A randomized clinical study. Scand J
Gastroenterol 2002; 37(7); 834-839.
II. Vetrhus M, Søreide O, Nesvik I, Søndenaa K. Acute cholecystitis: Delayed surgery or
observation. A randomized clinical trial. Scand J Gastroenterol 2003; 38(9):985-990.
III. Vetrhus M, Søreide O, Eide GE, Solhaug JH, Nesvik I, Søndenaa K. Pain and quality of life
in patients with symptomatic, non-complicated gallbladder stones: Results of a randomized
controlled trial. Scand J Gastroenterol 2004; 39(3):270-276.
IV. Vetrhus M, Søreide O, Eide GE, Nesvik I, Søndenaa K. Quality of life and pain in patients
with acute cholecystitis. Results of a randomized clinical trial. Scand J Surg 2005; 94(1):34-
39.
V. Vetrhus M, Berhane T, Søreide O, Søndenaa K. Pain persists in many patients five years
after removal of the gallbladder: observations from two randomized controlled trials of
symptomatic, noncomplicated gallstone disease and acute cholecystitis. J Gastrointest Surg.
2005; 9(6):826-31.
Fri, 27 Jan 2006 00:00:00 GMThttp://hdl.handle.net/1956/11012006-01-27T00:00:00Z